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CerclagefortheManagementofCervicalInsufficiency 1 Cervicalinsufficiency definition Theinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions orlabor orbothinthesecondtrimester Uterinecervix Absenceofthesignsandsymptoms Secondtrimester Ashortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis 2 CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalm lleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon Cervicalinsufficiency etiology 3 Cervicalinsufficiency diagnosis Challengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology 4 CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency Cervicalinsufficiency diagnosis Shortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency 5 Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindex Cervicalinsufficiency diagnosis 6 Cervicalinsufficiency treatmentoptions Non surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrest Non surgicaltreatmentTransvaginalcervicalcerclage McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage laparotomy laparoscopyandRobotic assisted 7 Cervicalinsufficiency treatmentoptions InwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered Failedtransvaginalcervicalcerclageprocedureshistory 这个我持保留意见 Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations 8 Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency physicalexaminationfindings orahistoryofpretermbirthandcertainultrasonographicfindings Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved Cervicalinsufficiency clinicalconsiderationsandrecommendations 9 IndicationsforCervicalCerclageinWomenWithSingletonPregnancies 10 IndicationsforCervicalCerclageinWomenWithSingletonPregnancies History IndicatedCerclage OneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup PhysicalExamination IndicatedCerclage Giventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity 11 Questions1 Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions 12 Cerclageversusnocerclageinpatientswithshortcervicallength Ultrasound indicatedcerclage 13 Questions2 Whichpatientsshouldnotbeconsideredcandidatesforcerclage 1 Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth Vaginalprogesteroneisrecommendedtopreventcervicallength 20mmbefore24wks 2 Twinpregnancywithcervicallength 25mm 3 Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications priorLEEP conebiopsy orm lleriananomaly 14 Questions3 Iscerclageplacementassociatedwithanincreaseinmorbidity 1 Lowriskofcomplicationswithcerclageplacement 2 Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage 3 Life threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported 4 Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage 15 Questions4 Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement 1 Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage regardlessoftimingorindication 2 Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary 16 Questions5 WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications andwhatistheappropriatesettingforremoval Cerclageremovalisrecommendedat36 37weeksofgestationinpatientswithnocomplications Inpatientsplannedvaginaldelivery removecerclagebeforelabor Inpatientselectedcesareandelivery removecerclageatthetimeofdelivery Inmostcases removalofaMcDonaldcerclageintheofficesettingisappropriate 17 Questions6 Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade andeitherremovalorretentionisreasonable Regardless ifacerclageremainsinplacewithPPROM prolongedantibioticprophylaxisbeyond7daysisnotrecommended 18 Questions7 Shouldcerclageberemovedinwomenwithpretermlabor Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage Inapatientwhopresentswithsymptomsofpretermlabor clinicaljudgmentaboutcerclageremovalisadvised Ifcervicalchange painfulcontractions orvaginalbleedingprogress cerclageremovalisrecommended 19 SummaryofRecommendationsandConclusions Singletonpregnancy Priorspontaneouspretermbirth 34wks Cervicallength 25mmbefore24wks Cerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings levelA Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength 25mmbefore24wksonly levelA 20 SummaryofRecommendationsandConclusions Certainnonsurgicalapproaches includingactivityrestriction bedrest andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged levelB ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished levelB 麦当劳更简单一些 21 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 22 SummaryofRecommendationsandConclusions Ahistory indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond trimesterdeliveryintheabsenceoflabororabruptioplacentae levelB Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved levelC 这个显然和临床有些不符合 23 SummaryofRecommendationsandConclusions Transabdominalcerclagegenerallyisreservedforpatientswithanatomicallimitations orinthecaseoffailedtransvaginalcervicalcerclageproceduresthatresultedinsecond trimesterpregnancyloss levelC 这个也是有争议的 Inpatientswithnocomplications transvaginalMcDonaldcerclageremovalisrecommendedat36 37wksofgestation levelC 24 SummaryofRecommendationsandConclusions Afterclinicalexaminationtoruleoututerineactivity orintraamnioticinfection orboth physicalexamination indicatedcerclageplacementinpatientswithsingletongestationswhohavecervicalchangeoftheinternalosmaybebeneficial levelC Forpatientswhoelectcesareandeliveryatorbeyond39weeksofgestation cerclageremovalatthetimeofdeliverymaybeperformed however thepossibilityofspontaneouslaborbetween37weeksand39weeksofgestationmustbeconsidered levelC 25 产