CerclagefortheManagementofCervicalInsufficiency.CerclagefortheManagementof1Cervicalinsufficiency:definitionTheinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions,orlabor,orbothinthesecondtrimester。UterinecervixAbsenceofthesignsandsymptomsSecondtrimesterAshortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis..Cervicalinsufficiency:defini2CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalmülleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon.Cervicalinsufficiency:etiology.CervicalconizationCervicalin3Cervicalinsufficiency:diagnosisChallengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria.DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology.Cervicalinsufficiency:diagno4CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency?Cervicalinsufficiency:diagnosisShortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency..Cantheidentificationofcerv5Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency.HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindexCervicalinsufficiency:diagnosis.Diagnostictestsshouldnotbe6Cervicalinsufficiency:treatmentoptionsNon-surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrestNon-surgicaltreatmentTransvaginalcervicalcerclage:McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage:laparotomy,laparoscopyandRobotic-assisted.Cervicalinsufficiency:treatm7Cervicalinsufficiency:treatmentoptionsInwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered?Failedtransvaginalcervicalcerclageprocedureshistory（這個我持保留意見）Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations.Cervicalinsufficiency:treatm8Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency,physicalexaminationfindings,orahistoryofpretermbirthandcertainultrasonographicfindings.Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.Cervicalinsufficiency:clinicalconsiderationsandrecommendations.Cerclageplacementmaybeindi9IndicationsforCervicalCerclageinWomenWithSingletonPregnancies.IndicationsforCervicalCercl10IndicationsforCervicalCerclageinWomenWithSingletonPregnanciesHistory-IndicatedCerclageOneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup.PhysicalExamination-IndicatedCerclageGiventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit,womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity..IndicationsforCervicalCercl11Questions1:Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency?Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions:.Questions1:Whatistherole12CerclageversusnocerclageinpatientswithshortcervicallengthUltrasound-indicatedcerclage.Cerclageversusnocerclagein13Questions2:Whichpatientsshouldnotbeconsideredcandidatesforcerclage?1.Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth.Vaginalprogesteroneisrecommendedtopreventcervicallength≤20mmbefore24wks.2.Twinpregnancywithcervicallength≤25mm.3.Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications:priorLEEP,conebiopsy,ormülleriananomaly..Questions2:Whichpatientssh14Questions3:Iscerclageplacementassociatedwithanincreaseinmorbidity?1.Lowriskofcomplicationswithcerclageplacement.2.Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage.3.Life-threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported.4.Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage..Questions3:Iscerclageplace15Questions4:Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement?1.Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.2.Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary..Questions4:Istherearolef16Questions5:WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications,andwhatistheappropriatesettingforremoval?Cerclageremovalisrecommendedat36–37weeksofgestationinpatientswithnocomplications.Inpatientsplannedvaginaldelivery,removecerclagebeforelabor.Inpatientselectedcesareandelivery,removecerclageatthetimeofdelivery.Inmostcases,removalofaMcDonaldcerclageintheofficesettingisappropriate..Questions5:Whenisremovalo17Questions6:Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged?AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade,andeitherremovalorretentionisreasonable.Regardless,ifacerclageremainsinplacewithPPROM,prolongedantibioticprophylaxisbeyond7daysisnotrecommended..Questions6:Howshouldwomen18Questions7:Shouldcerclageberemovedinwomenwithpretermlabor?Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage.Inapatientwhopresentswithsymptomsofpretermlabor,clinicaljudgmentaboutcerclageremovalisadvised.Ifcervicalchange,painfulcontractions,orvaginalbleedingprogress,cerclageremovalisrecommended..Questions7:Shouldcerclageb19SummaryofRecommendationsandConclusionsSingletonpregnancyPriorspontaneouspretermbirth＜34wksCervicallength≤25mmbefore24wksCerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings.(levelA)Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength≤25mmbefore24wksonly.(levelA).SummaryofRecommendationsand20SummaryofRecommendationsandConclusionsCertainnonsurgicalapproaches,includingactivityrestriction,bedrest,andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged.(levelB)ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques.Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished.(levelB)麥當勞更簡單一些。.SummaryofRecommendationsand21SummaryofRecommendationsandConclusionsCerclagemayincreasetheriskofpretermbirthinwomenwithatwinpregnancyandanultrasonographicallydetectedcervicallengthlessthan25mmandisnotrecommended.(levelB)Neitherantibioticsnorprophylactictocolyticshavebeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.(levelB)從一些新近的一些研究結(jié)果來看，目前尚有爭議。.SummaryofRecommendationsand22SummaryofRecommendationsandConclusionsAhistory-indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond-trimesterdeliveryintheabsenceoflabororabruptioplacentae.(levelB)Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.(levelC)這個顯然和臨床有些不符合。.SummaryofRecommendationsand23SummaryofRecommendationsandConclusionsTransabdominalcerclagegenerallyisreservedforpatientswithanatomicallimitations,orinthecaseoffailedtransvaginalcervicalcerclageproceduresthatresultedinsecond-trimesterpregnancyloss.(levelC)這個也是有爭議的。Inpatientswithnocomplications,transvaginalMcDonaldcerclageremovalisrecommendedat36–37wksofgestation.(levelC).SummaryofRecommendationsand24SummaryofRecommendationsandConclusionsAfterclinicalexaminationtoruleoututerineactivity,orintraamnioticinfection,orboth,physicalexamination-indicatedcerclageplacementinpatientswithsingletongestationswhohavecervicalchangeoftheinternalosmaybebeneficial.(levelC)Forpatientswhoelectcesareandeliveryatorbeyond39weeksofgestation,cerclageremovalatthetimeofdeliverymaybeperformed;however,thepossibilityofspontaneouslaborbetween37weeksand39weeksofgestationmustbeconsidered.(levelC).SummaryofRecommendationsand25產(chǎn)科問題產(chǎn)科、婦科宮頸機能不全Cervicalinsufficiency:thinkingabouttransabdominalcerclage.產(chǎn)科問題產(chǎn)科、婦科宮頸機能不全Cervicalinsuff26檢索關(guān)鍵詞英文關(guān)鍵詞：Laparoscopiccerclage中文關(guān)鍵詞：腹腔鏡宮頸環(huán)扎數(shù)據(jù)庫英文數(shù)據(jù)庫：pubmed,WebOfScience,Scopus中文數(shù)據(jù)庫：萬方、中國知網(wǎng)、中國生物醫(yī)學文獻數(shù)據(jù)庫文獻類型：論著、病例報道文獻發(fā)表時間：2010-1-1至2016-10-31Cervicalinsufficiency:thinkingabouttransabdominalcerclage.檢索關(guān)鍵詞Cervicalinsufficiency:t27文獻檢索結(jié)果webofscience:26篇pubmed:64篇scopus:81篇中國生物醫(yī)學文獻數(shù)據(jù)庫：6篇中國知網(wǎng)：21篇萬方數(shù)據(jù)庫：29篇共227例.文獻檢索結(jié)果webofscience:26篇.28文獻篩選排除重復文獻排除綜述排除非主題相關(guān)文獻排除不同語言發(fā)表的同一文獻排除同一醫(yī)學中心既往發(fā)表的相同主題文獻排除不能獲得全文文獻.文獻篩選排除重復文獻.29共34篇中英文文目前研究關(guān)注的是：環(huán)扎的成功率和手術(shù)相關(guān)的并發(fā)癥。目前研究尚未關(guān)注的是：環(huán)扎后對產(chǎn)科的影響。Cervicalinsufficiency:thinkingabouttransabdominalcerclage.共34篇中英文文Cervicalinsufficiency30產(chǎn)科問題產(chǎn)科、婦科宮頸機能不全Cervicalinsufficiency:thinkingabouttransabdominalcerclage.產(chǎn)科問題產(chǎn)科、婦科宮頸機能不全Cervicalinsuff31Cervicalinsufficiency:thinkingabouttransabdominalcerclage經(jīng)腹宮頸環(huán)扎對剖宮產(chǎn)手術(shù)的影響？經(jīng)腹宮頸環(huán)扎對中孕引產(chǎn)方式的影響？經(jīng)腹宮頸環(huán)扎患者先兆早產(chǎn)的臨床治療策略？經(jīng)腹宮頸環(huán)扎患者是否有必要進行促胎肺成熟？等等.Cervicalinsufficiency:thinki32CerclagefortheManagementofCervicalInsufficiency.CerclagefortheManagementof33Cervicalinsufficiency:definitionTheinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions,orlabor,orbothinthesecondtrimester。UterinecervixAbsenceofthesignsandsymptomsSecondtrimesterAshortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis..Cervicalinsufficiency:defini34CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalmülleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon.Cervicalinsufficiency:etiology.CervicalconizationCervicalin35Cervicalinsufficiency:diagnosisChallengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria.DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology.Cervicalinsufficiency:diagno36CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency?Cervicalinsufficiency:diagnosisShortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency..Cantheidentificationofcerv37Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency.HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindexCervicalinsufficiency:diagnosis.Diagnostictestsshouldnotbe38Cervicalinsufficiency:treatmentoptionsNon-surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrestNon-surgicaltreatmentTransvaginalcervicalcerclage:McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage:laparotomy,laparoscopyandRobotic-assisted.Cervicalinsufficiency:treatm39Cervicalinsufficiency:treatmentoptionsInwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered?Failedtransvaginalcervicalcerclageprocedureshistory（這個我持保留意見）Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations.Cervicalinsufficiency:treatm40Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency,physicalexaminationfindings,orahistoryofpretermbirthandcertainultrasonographicfindings.Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.Cervicalinsufficiency:clinicalconsiderationsandrecommendations.Cerclageplacementmaybeindi41IndicationsforCervicalCerclageinWomenWithSingletonPregnancies.IndicationsforCervicalCercl42IndicationsforCervicalCerclageinWomenWithSingletonPregnanciesHistory-IndicatedCerclageOneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup.PhysicalExamination-IndicatedCerclageGiventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit,womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity..IndicationsforCervicalCercl43Questions1:Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency?Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions:.Questions1:Whatistherole44CerclageversusnocerclageinpatientswithshortcervicallengthUltrasound-indicatedcerclage.Cerclageversusnocerclagein45Questions2:Whichpatientsshouldnotbeconsideredcandidatesforcerclage?1.Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth.Vaginalprogesteroneisrecommendedtopreventcervicallength≤20mmbefore24wks.2.Twinpregnancywithcervicallength≤25mm.3.Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications:priorLEEP,conebiopsy,ormülleriananomaly..Questions2:Whichpatientssh46Questions3:Iscerclageplacementassociatedwithanincreaseinmorbidity?1.Lowriskofcomplicationswithcerclageplacement.2.Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage.3.Life-threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported.4.Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage..Questions3:Iscerclageplace47Questions4:Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement?1.Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.2.Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary..Questions4:Istherearolef48Questions5:WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications,andwhatistheappropriatesettingforremoval?Cerclageremovalisrecommendedat36–37weeksofgestationinpatientswithnocomplications.Inpatientsplannedvaginaldelivery,removecerclagebeforelabor.Inpatientselectedcesareandelivery,removecerclageatthetimeofdelivery.Inmostcases,removalofaMcDonaldcerclageintheofficesettingisappropriate..Questions5:Whenisremovalo49Questions6:Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged?AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade,andeitherremovalorretentionisreasonable.Regardless,ifacerclageremainsinplacewithPPROM,prolongedantibioticprophylaxisbeyond7daysisnotrecommended..Questions6:Howshouldwomen50Questions7:Shouldcerclageberemovedinwomenwithpretermlabor?Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage.Inapatientwhopresentswithsymptomsofpretermlabor,clinicaljudgmentaboutcerclageremovalisadvised.Ifcervicalchange,painfulcontractions,orvaginalbleedingprogress,cerclageremovalisrecommended..Questions7:Shouldcerclageb51SummaryofRecommendationsandConclusionsSingletonpregnancyPriorspontaneouspretermbirth＜34wksCervicallength≤25mmbefore24wksCerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings.(levelA)Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength≤25mmbefore24wksonly.(levelA).SummaryofRecommendationsand52SummaryofRecommendationsandConclusionsCertainnonsurgicalapproaches,includingactivityrestriction,bedrest,andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged.(levelB)ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques.Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished.(levelB)麥當勞更簡單一些。.SummaryofRecommendationsand53SummaryofRecommendationsandConclusionsCerclagemayincreasetheriskofpretermbirthinwomenwithatwinpregnancyandanultrasonographicallydetectedcervicallengthlessthan25mmandisnotrecommended.(levelB)Neitherantibioticsnorprophylactictocolyticshavebeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.(levelB)從一些新近的一些研究結(jié)果來看，目前尚有爭議。.SummaryofRecommendationsand54SummaryofRecommendationsandConclusionsAhistory-indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond-trimesterdeliveryintheabsenceoflabororabruptioplacentae.(levelB)Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.(levelC)這個顯然和臨床有些不符合。.SummaryofRecommendationsand55SummaryofRecommen