单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2018/2/6,#,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 symptoms,Second trimester,A short,cervical length in the second trimester,is,not sufficient for the,diagnosis.,Cervical conization,LEEP,Mechanical dilation,Obstetric lacerations,Congenital mllerian anomalies,Deficiencies in,cervical collagen and,elastin,Utero exposure,to,diethylstilbestrol,And so on.,Cervical insufficiency:etiology,Cervical insufficiency:diagnosis,Challenging because,of a lack of objective findings and clear diagnostic,criteria.,Diagnosis,is based on,history,Painless cervical dilation and expulsion,of the,pregnancy in,the second,trimester,Without contractions,or,labor,In the,absence of other 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 insufficiency.,Diagnostic tests should not be used to diagnose cervical insufficiency.,Hysterosalpingography,Radiographic imaging,of balloon traction on the,cervix,Assessment of,the patulous cervix with Hegar or,Pratt dilators,Balloon elastance test,Cervical dilators,to calculate a cervical,resistance index,Cervical insufficiency:diagnosis,Cervical insufficiency:treatment options,Non-surgical treatment,Vaginal progesterone,Vaginal pessary,Activity restriction,Bed rest,Pelvic rest,Non-surgical,treatment,Transvaginal cervical cerclage:McDonald,procedure,and Shirodkar procedure,Transabdominal cervical,cerclage:laparotomy,laparoscopy and Robotic-assisted,Cervical insufficiency:treatment options,In which situations should Transabdominal cervical cerclage be considered?,Failed transvaginal cervical cerclage procedures history（这个我持保留心见）,Transvaginal cervical cerclage procedures can not place because of anatomical 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.,Cervical insufficiency:clinical considerations and recommendations,Indications for Cervical Cerclage in,Women With Singleton Pregnancies,Indications for Cervical Cerclage in,Women With Singleton Pregnancies,History-Indicated 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 and perinatal morbidity.,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,:,Cerclage versus no cerclage in patients with short cervical length,Ultrasound-indicated cerclage,Questions 2:,Which patients should not be,considered 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 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-threatening,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,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.,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 delivery,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,appr