宫颈机能不全与宫颈环扎术

宫颈机能不全的特点是在妊娠中、晚期出现的无痛性宫颈扩张和缩短,是引起反复晚期流产及早产的常见原因。由于宫颈机能不全的诊断难以精准,其发病机制尚不明确,国内外尚无统一的规范。作为一种监测手段,经阴道超声监测宫颈长度对治疗有一定的指导作用。宫颈环扎术是宫颈机能不全最简单有效的治疗方式,根据手术方式可分为经阴道宫颈环扎术和经腹宫颈环扎术,根据手术指征可分为病史指征的宫颈环扎术、超声指征的宫颈环扎术和紧急环扎术。宫颈环扎术的术后管理及拆线时机需进行个性化选择。     

宫颈机能不全患者采用不同指证McDonald子宫颈环扎术对足月分娩的影响

目的:探讨不同指证McDonald子宫颈环扎术对宫颈机能不全患者足月分娩影响。方法:回顾性收集2016年8月-2018年10月本院治疗的宫颈机能不全患者102例。根据McDonald的手术时机不同分为3组各34例。病史指证组行基于病史指征性的McDonald子宫颈环扎术,阴道超声组采取经阴道彩色超声联合McDonald子宫颈环扎术,体格指证组行体格检查指征性环扎术。对比3组手术成功率、妊娠结局、新生儿情况。结果:成功率、分娩孕周、足月分娩率、新生儿体质量及存活率,病史指证组及阴道超声组均高于体格指证组(P<0.05),但病史指证组与阴道超声组对比无差异(P>0.05)。流产率、早产率3组无差异(P>0.05)。结论:不同手术指征对McDonald子宫颈环扎术治疗宫颈机能不全效果存在差异,经阴道彩超联合McDonald子宫颈环扎术及基于病史指征性的McDonald子宫颈环扎术手术成功率、分娩孕周、足月分娩率、新生儿体质量及存活率均优于体格检查指征性环扎术。     

Vaginal fetal fibronectin as a predictor of spontaneous preterm delivery in the patient with cervical cerclage

OBJECTIVE: The purpose of this study was to assess the validity of vaginal fetal fibronectin as a screening test for spontaneous preterm birth in patients with cervical cerclage. STUDY DESIGN: A historic cohort of 117 patients who underwent cervical cerclage placement between 1996 and 2002 were identified. All patients were followed up in a maternal-fetal medicine faculty practice in a university setting. Serial fetal fibronectin samples of vaginal secretions were collected every 2 to 3 weeks, starting at 22 weeks of gestation and continuing until 32 weeks or delivery, whichever came first. RESULTS: There were 81 singleton, 23 twin, 12 triplet, and 1 quadruplet pregnancies. There were 61 ultrasound-indicated, 47 prophylactic, and 9 emergency cerclages that were placed. Most cerclages were of the modified Shirodkar type (95%) with a median gestational age at cerclage placement of 16.6 weeks. Overall, 33.3% of gestations were delivered spontaneously before 37 weeks of gestation; 17.1% of gestations were delivered spontaneously before 34 weeks. For deliveries within 2 weeks and 3 weeks of a single fetal fibronectin assessment, the test had a sensitivity of 50% and 48.3%, a specificity of 90% and 91.1%, a positive predictive value of 16.3% and 28.6%, and a negative predictive value of 97.9% and 96%, respectively. Subgroup analysis by number of fetuses (singleton, twin, and higher order multiple gestations) revealed similar values. For delivery before 34 weeks of gestation, fetal fibronectin had a sensitivity of 50%, a specificity of 78.4%, a positive predictive value of 33.3%, and a negative predictive value of 88%. CONCLUSION: This study is the first to evaluate the use of vaginal fetal fibronectin assessments to screen for preterm birth in patients who had undergone cervical cerclage procedures. We conclude that this test has similar validity to predict spontaneous preterm delivery in these high-risk pregnancies, as in previously published cohorts.     

包皮环扎与包皮环切术在小儿外科应用比较

目的利用包皮环扎与包皮环切在小儿外科患者中进行临床比较。方法随机对小儿包茎、包皮过长患者不分年龄大小分别采用两种手术方式，在安全性、术式优越性、疗效方面进行对比。结果在手术时间、术中出血量、术后护理、术中术后出血、残端规整、术后感染等方面，环扎组明显优于环切组（P〈0．05），差异有统计学意义。结论包皮环扎是目前治疗包茎、包皮过长较先进的手术方法，经济简便，符合现代微创要求值得提倡，尤其适合在基层医院开展。     

加长PFNA结合钛缆环扎术治疗股骨转子下长斜形及螺旋形骨折疗效观察

目的:探讨应用加长亚洲型股骨近端髓内钉(PFNA)结合钛缆环扎术治疗股骨转子下长斜形及螺旋形骨折的方法及疗效。方法:2010年8月至2013年2月,收治22例股骨转子下长斜形及螺旋形骨折患者,按Zickel分型均为1B型;其中男16例,女6例;年龄24-78岁,平均66.3岁。均在C型臂X线机透视下采用加长PFNA结合钛缆环扎术治疗,术后髋关节功能采用Harris评分。结果:所有患者均获得随访,随访时间6-36个月,平均20.2个月。骨折全部愈合,愈合时间为9-16周,平均12.4周。均未出现感染、髋内翻畸形、下肢外旋及短缩畸形、螺旋刀片切割股骨头、股骨干骨折、内固定失效及延迟骨愈合等并发症。患者按Harris髋关节功能评分标准优13例,良7例,可2例,优良率为90.9%。结论:PFNA结合钛缆环扎术治疗股骨转子下长斜形及螺旋形骨折具有操作简单、创伤小、内固定牢靠、可早期功能锻炼及术后并发症少等优点,临床疗效良好。     

Does cervical cerclage decrease preterm birth in twin pregnancies with a short cervix?

Purpose: To determine if use of cerclage in twin gestations with mid-trimester short cervix is associated with decreased preterm birth rate.

Study design: This is a retrospective cohort of twin gestations identified with cervical length of ≤2.5?cm before 24 weeks of gestation through the perinatal ultrasound database of two institutions from 2008 to 2014. Patients with and without cerclage were compared for a primary outcome of preterm birth at <35 weeks. A pre-planned sub-group analysis of patients with cervical length ≤1.5?cm was also performed.

Results: Eighty-two patients were included; 43 received cerclage, 39 did not. Mean gestational age at cerclage placement was 20.8 weeks. There was no significant difference in rate of preterm birth <35 weeks between the groups (34.9% versus 48.7%, respectively). In the sub-group analysis of patients with cervical length ≤1.5?cm, there was a significant decreased risk of preterm birth <35 weeks [37% versus 71.4%; adjusted RR 0.49 (0.26–0.93)].

Conclusion: Cerclage placement for cervical length ≤2.5?cm in twin gestations did not decrease the rate of preterm birth at <35 weeks; however, cerclage placement for cervical length ≤1.5?cm was associated with a significantly decreased rate of preterm birth <35 weeks when compared to patients managed without cerclage.     

Elective removal of cervical cerclage and onset of spontaneous labor

Objective

To determine the time interval between elective removal of cervical cerclage and onset of spontaneous labor.

Methods

A retrospective cohort study was conducted between January 2005 and December 2012 at a tertiary care hospital in Lisbon, Portugal. All singleton pregnancies with a McDonald or Shirodkar cerclage electively removed at 36–37 weeks were evaluated for the time interval between cerclage removal and spontaneous labor. Delivery within 72 hours after cerclage removal was compared between patients with elective cerclage and those with non-elective cerclage. In the non-elective group, a sub-analysis of the results for ultrasound- and physical examination-indicated cerclage was performed.

Results

Thirty-eight women were included. The time interval between cerclage removal and spontaneous labor did not differ significantly between the elective and the non-elective group (15.6 ± 7.6 vs 10.9 ± 7.4 days; P = 0.063). A higher incidence of delivery 72 hours after cerclage removal was seen in the non-elective group but this was not significant (P = 0.061). There were no differences regarding the time interval from elective removal of cervical cerclage to onset of spontaneous labor between ultrasound-indicated and physical examination-indicated cerclage.

Conclusion

Regardless of the indication for cervical cerclage, the probability of delivery soon after elective cerclage removal is low.     

Intrathecal bupivacaine versus chloroprocaine for transvaginal cervical cerclage placement: a retrospective cohort study

BackgroundBupivacaine is commonly used in spinal anesthesia for cervical cerclage placement, but its long duration of action can delay hospital discharge. Chloroprocaine has a short duration of action and has re-emerged as an agent for ambulatory neuraxial anesthesia. There are limited data comparing intrathecal bupivacaine and chloroprocaine when used for cerclage placement. This retrospective study compares the time to hospital discharge between these drugs when used in spinal anesthesia for cervical cerclage placement.MethodsA retrospective analysis of patients who underwent transvaginal cerclage placement under neuraxial anesthesia with intrathecal hyperbaric bupivacaine or plain chloroprocaine between January 1, 2015 and October 31, 2020. The primary outcome was the time to hospital discharge. Secondary outcomes included the incidence of inadequate anesthesia, postoperative pain scores and postoperative neurologic symptoms.ResultsThree hundred and sixty patients were included in the final analysis (bupivacaine n=236, chloroprocaine n=124). The median (IQR) intrathecal dose was 7.5 (7.5, 9) mg and 45 (45, 50) mg in the bupivacaine and chloroprocaine groups respectively. The time (median [IQR]) from spinal anesthesia to hospital discharge was significantly shorter in the chloroprocaine group compared with the bupivacaine group (218 [180, 253] vs. 370 [309, 424] min, P<0.001). There were no significant differences between the groups for secondary outcomes and neither group had a patient report neurologic symptoms.ConclusionWhen utilized in spinal anesthesia for transvaginal cervical cerclage placement, chloroprocaine may reduce the time to discharge while providing comparable anesthesia to that provided by bupivacaine.     

Cerclage wiring and intramedullary nailing,a helpful and safe option specially in proximal fractures. A multicentric study

Purpose

Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment.