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1、Cerclage for the Management of Cervical Insufficiency,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 sympto
2、ms,Second trimester,A short cervical length in the second trimester is not sufficient for the diagnosis.,Cervical conizationLEEPMechanical dilationObstetric lacerationsCongenital mllerian anomaliesDeficiencies in cervical collagen and elastinUtero exposure to diethylstilbestrolAnd so on.,Cervical in
3、sufficiency:etiology,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 trimesterWithout contractions or laborIn the absence of other
4、clear pathology,Can the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?,Cervical insufficiency:diagnosis,Short cervical length has been shown to be a marker of preterm birth in general rather than a specific marker of cervical insuffic
5、iency.,Diagnostic tests should not be used to diagnose cervical insufficiency.HysterosalpingographyRadiographic imaging of balloon traction on the cervixAssessment of the patulous cervix with Hegar or Pratt dilatorsBalloon elastance testCervical dilators to calculate a cervical resistance index,Cerv
6、ical insufficiency:diagnosis,Cervical insufficiency:treatment options,Non-surgical treatmentVaginal progesteroneVaginal pessary Activity restriction Bed rest Pelvic rest,Non-surgical treatmentTransvaginal cervical cerclage:McDonald procedure and Shirodkar procedureTransabdominal cervical cerclage:la
7、parotomy,laparoscopy and Robotic-assisted,Cervical insufficiency: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
8、 limitations,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.,
9、Cervical insufficiency:clinical considerations and recommendations,Indications for Cervical Cerclage inWomen With Singleton Pregnancies,Indications for Cervical Cerclage inWomen With Singleton Pregnancies,History-Indicated Cerclage,One in three RCT indicated fewer deliveries before 33 weeks of gesta
10、tion 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 and perinatal morbidity.,Questions 1:What is the role of ultrasonography in managi
11、ng women with a history of cervical insufficiency?,Two recent summaries of the results of these multiple studies have drawn the following conclusions:,Cerclage versus no cerclage in patients with short cervical length,Ultrasound-indicated cerclage,Questions 2:Which patients should not be considered
12、candidates for cerclage?,1.Short cervical length without history of prior singleton 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
13、 indications:prior LEEP,cone biopsy,or mllerian anomaly.,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-thre
14、atening complications of uterine rupture and maternal septicemia are rare but have been reported.,4.Transabdominal cerclage carries a much greater risk of hemorrhage.,Questions 4:Is there a role for additional perioperative interventions and postoperative ultrasonographic assessment with cerclage pl
15、acement?,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.,Questions 5:When is removal of transvaginal McDonald
16、 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 delivery,remove cerclage before labor.,In patients elected cesarean deliver
17、y,remove cerclage at the time of delivery.,In most cases,removal of a McDonald cerclage in the office setting is appropriate.,Questions 6:How should women with cerclage and preterm premature rupture of membranes be managed?,A firm recommendation on whether a cerclage should be removed after PPROM ca
18、nnot be made,and either removal or retention is reasonable.,Regardless,if a cerclage remains in place with PPROM,prolonged antibiotic prophylaxis beyond 7 days is not recommended.,Questions 7:Should cerclage be removed in women with preterm labor?,The diagnosis of preterm labor may be more difficult
19、 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 removal is recommended.,Summary of Recommendations and Conclusions,Singleton pregnanc
20、y,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 findings.(level A),Cerclage is not associated with a significant reduction in preterm birth in patents with cervical length 25mm befor
21、e 24 wks only.(level A),Summary of Recommendations 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
22、cerclage methods currently 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 Recommendations and Conclusions,Cerclage may increase the risk of preterm birth
23、in women with a twin pregnancy and an ultrasonographically detected cervical 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。,
24、Summary of Recommendations 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 viabil
25、ity has been achieved.(level C)这个显然和临床有些不符合。,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-trimester pregnancy loss.(level C)
26、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),Summary of Recommendations and Conclusions,After clinical examination to rule out uterine activity,or intraamniotic infection,or both,physical examination-indicated ce
27、rclage 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
28、labor between 37 weeks and 39 weeks of gestation must be considered.(level C),产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency:thinking about transabdominal cerclage,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2016-1
29、0-31,Cervical insufficiency:thinking about transabdominal cerclage,文献检索结果,web 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,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,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:thinking about transabdominal cerclage,产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency:thinking about transabdominal cerclage,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,
