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 sym

2、ptoms,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.,C

3、ervical 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 ab

4、sence 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 c

5、ervical 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

6、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 Transab

7、dominal 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（這個我持保留意見） Transvaginal cervical cerclage procedures ca

8、n 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

9、 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 fe

10、wer 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

11、 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

12、: 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 th

13、e 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

14、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 pos

15、toperative 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 neces

16、sary.,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, remov

17、e 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 appropriate.,Questions 6: How should women with cerclage and preterm premature rupture of membranes be managed?,A firm recom

18、mendation on whether a cerclage should be removed after PPROM cannot 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

19、 preterm labor?,The diagnosis of preterm labor may be more difficult 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 r

20、ecommended.,Summary of Recommendations and Conclusions,Singleton pregnancy,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 signifi

21、cant reduction in preterm birth in patents with cervical length 25mm before 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 i

22、nsufficiency and their use is discouraged. (level B),The standard transvaginal 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) 麥當(dāng)勞更簡單一些。,Summary o

23、f Recommendations and Conclusions,Cerclage may increase the risk of preterm birth 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 effic

24、acy of cerclage, regardless of timing or indication. (level B) 從一些新近的一些研究結(jié)果來看，目前尚有爭議。,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

25、),Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved. (level C) 這個顯然和臨床有些不符合。,Summary of Recommendations and Conclusions,Transabdominal cerclage generally is reserved for patients with anatomical limitations, or in the case of failed transvagin

26、al cervical cerclage procedures that resulted in second-trimester pregnancy loss.(level C) 這個也是有爭議的。,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 r

27、ule out uterine activity, or intraamniotic infection, or both, physical examination-indicated cerclage 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 po