孕期不同指征经阴道宫颈环扎术的效果评价

目的:回顾性分析孕期3种不同指征经阴道宫颈环扎术的妊娠结局和新生儿预后。方法:收集66例采用Mc Donald方法进行宫颈环扎术患者的临床资料。结果:病史指征性环扎组与超声指征性环扎组,在平均分娩孕周、活产率及新生儿平均出生体质量方面差异均无统计学意义(P0.05)。紧急性环扎组的分娩孕周(29.17±6.44)周均低于病史指征性环扎组的(34.06±6.66)周和超声指征性环扎组的(35.42±4.75)周,差异有统计学意义(P0.05)。紧急环扎组中手术失败孕妇在宫口开大程度、术后白细胞计数及C反应蛋白(CRP)最高值较手术成功孕妇高。结论:病史指征性环扎术和超声指征性环扎术均可获得良好的相似妊娠结局。术后加强抗炎可提高紧急性环扎手术的成功率。剖宫产再孕者有一定的发生宫颈机能不全的概率,孕期应B超监测宫颈的变化。     

经阴道宫颈环扎术式的循证医学评价

目前关于宫颈机能不全的定义和诊断标准,国内外尚未统一。宫颈机能不全的主要治疗方式为宫颈环扎术,目的在于纠正薄弱或存在缺陷的宫颈结构,延长孕周,降低早产风险。目前关于宫颈环扎术的指征、时机、方式以及术后的效果等意见尚不一致,参照临床循证医学的证据,本文对病史指征、超声指征、体格检查指征下的经阴道宫颈环扎术进行以下综述。     

紧急宫颈环扎术治疗晚期难免流产40例临床分析

目的探讨紧急宫颈环扎术治疗晚期难免流产的临床价值。方法选取2008年11月至2010年8月中国医科大学附属盛京医院晚期难免流产孕妇65例,40例施行紧急宫颈环扎术,25例未采取手术干预,仅用保胎药物,并卧床休息。统计入院时宫颈情况及术后延长孕周情况。结果 40例紧急宫颈环扎术均成功实施,对产妇无不良影响,平均延长孕期为53.30d。33例患者得存活新生儿。25例未实行紧急宫颈环扎术患者保胎失败23例,发生流产,延长孕期为4.48d。4例患者得存活新生儿。结论紧急宫颈环扎术能有效地延长宫颈机能不全患者的孕周,明显提高新生儿存活率。     

紧急宫颈环扎术的临床应用研究进展

正宫颈环扎术是治疗宫颈功能不全的主要手术方法之一,主要有预防性宫颈环扎术和治疗性宫颈环扎术,后者包括紧急宫颈环扎术。目前更多研究集中在宫颈功能不全及其预防性应用方面。在妊娠期间发现的宫颈扩张和/或胎囊脱出情形下的紧急宫颈环扎术,由于临床情形更加复杂,在手术指征和临床效果等研究报道还多有不一致,而且,基本上排除宫缩存在。对有规律宫缩伴宫颈变化的患者行紧急宫颈环扎术联合宫缩抑制剂的双重干预措施在临床应用方面,可降低     

宫颈环扎术的争议与观点

宫颈机能不全是导致晚期流产及早产的常见原因, 宫颈环扎术是治疗宫颈机能不全的有效方法。目前对于不同指征宫颈环扎术的手术时机、围术期处理及管理均存在分歧及争议。本文对目前宫颈环扎术存在的分歧和争议进行简要评述并进行观点阐述, 以期为临床决策及研究提供参考。     

紧急宫颈环扎术的应用价值探讨

宫颈机能不全(cervical insufficiency)是造成反复中晚期流产及早产的主要原因之一。宫颈环扎术(cervical cerclage)是治疗宫颈机能不全的主要手术方式之一,其治疗效果一直是国内外学者的研究热点。而紧急宫颈环扎术是为了延长发育正常但未发育成熟的胎儿孕周而采取的急症手术,在单胎及多胎妊娠疗效、分娩方式及术式选择、并发症的处理、围手术期的处理和管理以及妊娠结局等方面仍存在争议。综述紧急宫颈环扎术治疗宫颈机能不全的应用价值,为临床提供治疗依据。     

紧急宫颈环扎术联合不同宫缩抑制剂的效果和安全性评价

目的评价宫颈环扎术后联合不同宫缩抑制剂的效果和安全性。方法回顾性分析2015年1月至2019年12月在首都医科大学附属北京世纪坛医院妇产科行紧急宫颈环扎术,并在术后使用不同宫缩抑制剂的56例单胎妊娠患者,观察药物疗效、不良反应以及妊娠结局。结果紧急宫颈环扎术后使用阿托西班+吲哚美辛栓组的药物起效时间最短,成功率较高(P<0.05);盐酸利托君组药物不良反应较高60.00%,主要为心动过速(P<0.05)。结论紧急宫颈环扎术后联合阿托西班及吲哚美辛栓能延长妊娠时间,药物不良反应发生率较低,值得临床推广。     

预防性与紧急性宫颈环扎术治疗宫颈功能不全的效果分析

目的 分析预防性与紧急性宫颈环扎术治疗宫颈功能不全的效果。方法 选取本院74例宫颈功能不全的孕妇为研究对象,随机数字表法将其分为两组,各37例。对照组采用紧急性宫颈环扎术,观察组采用预防性宫颈环扎术。对比两组手术相关指标、分娩情况、并发症发生率及妊娠结局。结果 观察组术中出血量、住院时间小于对照组,妊娠延长时间、分娩孕周及妊娠32周宫颈长度大于对照组（P<0.05）;观察组并发症发生率低于对照组,足月产率和新生儿存活率高于对照组（P<0.05）。结论 预防性宫颈环扎术治疗孕妇宫颈功能不全,效果显著,能减少出血量,缩短住院时间,延长产妇妊娠时间和分娩孕周,并发症发生率低,妊娠结局好,值得临床推广。     

宫颈环扎术治疗孕中期宫颈机能不全的妊娠结局

目的:探讨宫颈环扎术治疗孕中期宫颈机能不全的疗效。方法:36例孕14-28周合并宫颈机能不全,采取宫颈环扎术治疗。结果:孕14-16周手术27例,延长妊娠时间至足月21例,早产3例,流产3例,胎儿成活23例;>16孕周手术9例,延长妊娠时间至足月4例,早产3例,流产2例,胎儿成活6例,两者无统计学差异(P>0.05)。结论:孕14-16周是宫颈环扎术最佳手术时机,>16孕周手术也可提高胎儿成活率,紧急宫颈环扎术是必要的,可以延长妊娠时间,提高活婴分娩率。     

宫颈环扎术的过去、现状和将来

宫颈机能不全是中晚期流产和早产的重要原因,其特点是无痛性宫颈扩张,通常不伴有子宫收缩和出血。多年来,宫颈环扎术是治疗宫颈机能不全的有效方法,本文聚焦宫颈环扎术,讨论宫颈环扎术的诊断、适应证、禁忌证、外科手术入路(经阴道,腹腔镜或开腹手术)、环扎手术时机(孕前或孕期环扎)、手术方式、技术的选择、缝线的正确放置位置、药物辅助治疗(如孕激素和抗生素)和宫颈环扎带的移除。腹腔镜宫颈环扎术的应用日益广泛,最近报道宫颈环扎术不必为了放置环扎带而分离下推膀胱,而是直接在子宫峡部进行环扎(极简式腹腔镜宫颈环扎术),这使术式的学习更容易、学习曲线更短,这一术式有深远的影响,将在不久的将来得到更为广泛的应用。     

宫颈环扎术并发症

宫颈环扎术是治疗宫颈机能不全的唯一有效方法,其并发症发生率低,相关报道少,严重并发症罕见。最常见的并发症包括胎膜早破、绒毛膜羊膜炎、子宫内膜炎、围手术期出血、宫颈裂伤、环扎线或环扎带移位等,少见的并发症有膀胱宫颈瘘、输尿管宫颈瘘等,经阴道环扎的并发症较经腹环扎多。并发症的发生率因宫颈环扎的时机及适应证的不同而异。并发症常随孕周的增加及宫颈的扩张而增多,当胎膜破裂或宫颈扩张时行环扎术会增加并发症的发生风险。故应严格掌握适应证与禁忌证,选择适合的手术时机。已证明宫颈环扎的穿刺点和环扎带的位置直接影响妊娠结局,环扎带越接近宫颈内口效果越好。宫颈环扎后一般要限制体力活动,适当卧床休息,若子宫的敏感性增高给予孕酮和保胎药物,有感染病史及感染迹象者给予抗生素,重视阴道感染的筛查与治疗,密切监测母胎情况,关注宫颈环扎可能出现的并发症。开腹或腹腔镜环扎需剖宫产分娩,如有产兆,应即刻施术,避免发生宫颈裂伤或子宫破裂。     

Interleukin-6 and tumor necrosis factor alpha as predictors of success after emergent cerclage

Serum levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) were measured in patients requiring an emergent cerclage to determine if they are predictive of successful pregnancy outcome. Women with a clinical diagnosis of cervical incompetence requiring an emergent cerclage between 15 and 24 weeks gestation were enrolled. Asymptomatic women of the same gestational age range were recruited as controls. IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay. Twenty-one women underwent emergent cerclage and participated in the study, 15 (71%) of whom delivered after 28 weeks. Twenty-one women served as controls. IL-6 levels were increased in women with cervical incompetence compared with control subjects, but there were no differences between cerclage success and failure groups. TNF-alpha was not increased in women with cervical incompetence and did not predict success of emergent cerclage. IL-6 levels were increased in women with cervical incompetence who required an emergent cerclage.     

Cerclage and cervical insufficiency: an evidence-based analysis

Since the cervical cerclage was introduced to clinical practice 50 years ago, the efficacy of the operation has not been established by evidence-based standards for many indications. Serious flaws in the methods employed to study the safety and efficacy of cerclage have led to confusion and misuse of the operation, although some investigators maintain that current standards make randomized clinical trials of this traditional surgery unethical. At present, five randomized clinical trials have offered significant information about elective cerclages performed for historical indications, and the expected neonatal survival rate with properly selected elective cerclages is around 87%.Transvaginal ultrasound studies have revealed new paradigms regarding normal cervical function in pregnancy and further understanding about the significance and predictive value of cervical changes at gestational ages between 20-37 weeks. Only two randomized clinical trials have been conducted regarding cerclage in women with decreasing cervical length or with cervical funneling. One of these two failed to demonstrate any resulting improvement in neonatal survival, and the other was too small to be conclusive.To date, no randomized clinical trials have been conducted to demonstrate the efficacy or safety of emergency cerclages performed for advanced cervical dilatation. The many retrospective case series regarding emergency cerclage have failed to provide an evidence-based solution to the management of this problem.Before this traditional surgery continues extensive use in clinical practice, it should be assessed rigorously with randomized clinical trials of sufficient statistical power and external validity to establish the appropriate indications for the operation. In addition, a more thorough understanding of cervical function and molecular biology is essential.     

宫颈环扎术在早产治疗中的应用

目的评估治疗性宫颈环扎术及预防性宫颈环扎术的效果。方法选择2003年1月至2006年3月北京大学第三医院的34周前的早产临产及宫颈机能不全患者,早产临产患者采取紧急宫颈环扎术联合宫缩抑制剂或者单纯使用宫缩抑制剂治疗。宫颈机能不全患者采取预防性宫颈环扎术、紧急环扎术以及非环扎保守治疗。对治疗结局进行统计学分析。结果在早产临产组,紧急宫颈环扎联合宫缩抑制剂（硫酸镁）来治疗早产,平均保胎天数45.00 d,较单纯用宫缩抑制剂硫酸镁抑制宫缩的34例患者保胎天数[中位数为1（0.75-16）d]明显延长,34、37周后分娩率分别为66.7%（26/39）、30.8%（12/39）,明显增加。宫颈机能不全患者预防性环扎及治疗性环扎均较非环扎组保胎天数延长,增加32、34周后的分娩率（P〈0.05）,但治疗性环扎可降低早产率（P=0.02）。结论观察资料结果显示早产临产患者硫酸镁联合宫颈环扎治疗早产效果更佳,增加34周以上的分娩率,降低早产率;预防性环扎不能降低37周前早产率,但能增加32、34周后分娩率,延长保胎天数;治疗性环扎可降低37周前早产率。     

Cervical incompetence: elective, emergent, or urgent cerclage.

OBJECTIVE: We define criteria for insertion of cervical cerclage done electively (historical), urgently (in patients without symptoms), or emergently (in patients with symptoms). We compare outcomes as determined by prolongation of pregnancy and survival in each of these groups, and we define whether urgent or emergent cerclage imparted a higher risk of spontaneous rupture of membranes or chorioamnionitis than that associated with elective cerclage. Study Design: This is a retrospective analysis of all cervical cerclages placed at Memorial Medical Center between January 1, 1993, and December 31, 1997. Outcomes oberved were as follows: (1) prolongation of pregnancy in weeks after cervical cerclage, (2) presence of spontaneous rupture of membranes or clinical chorioamnionitis necessitating delivery, and (3) neonatal outcome. RESULTS: For prolongation of pregnancy the following results were obtained: emergent cerclage, 8.3 +/- 0.9 weeks; urgent cerclage, 12.2 +/- 1.5 weeks; and elective cerclage, 20.2 +/- 0.9 weeks (elective versus emergent and urgent, P <.05). For average gestational age at delivery, the results were as follows: emergent cerclage, 30.5 +/- 0.9 weeks; urgent cerclage, 33.1 +/- 1.4 weeks; and elective cerclage, 35.5 +/- 0.9 weeks (elective versus emergent and urgent, P <.05). The total neonatal survival was 85.7%. The incidence of spontaneous rupture of membranes was as follows: emergent cerclage, 51%; urgent cerclage, 40%; elective cerclage, 18% (elective versus emergent and urgent, P <.05). The incidence of clinical chorioamnionitis showed similar results. CONCLUSIONS: It is clear that emergency cerclages confer some benefit in patients with evidence of cervical incompetence. From this study it is evident that there is a new group of patients who need cerclage on an urgent basis as shown by subtle ultrasonographic changes in the cervix. Their behavior mirrors that of those belonging to the emergent group, suggesting that if they were left untreated they would need cerclage on an emergency basis.     

Elective and emergency transabdominal cervicoisthmic cerclage for cervical incompetence

OBJECTIVE: To evaluate the success rate of transabdominal cervicoisthmic cerclage (TACIC) as an elective and emergency procedure for cervical incompetence in comparison to reported success rates for vaginal cerclage. STUDY DESIGN: Retrospective review was performed of the hospital records of patients and their neonates who underwent TACIC for cervical incompetence by the Maternal-Fetal Medicine Service, Harrisburg Hospital. Data regarding procedure indications, maternal age, gravidity/parity, gestational age at time of placement, pregnancy outcome, delivery age and fetal weight at delivery were recorded. Comparison was made to previously reported outcomes for vaginal cerclage. RESULTS: Thirteen patients underwent TACIC from July 1996 through April 2001. The overall viable delivery rate was 76.9%. Five procedures were emergency, with a viable delivery rate of 60%. Mean gestational age at delivery for this group was 34.6 weeks. The 8 elective procedures had a viable delivery rate of 87.5% and mean gestational age of 35.5 weeks. Complications from the TACIC procedure were limited to a single catheter-related urinary tract infection. CONCLUSION: In pregnancies complicated by cervical incompetence and in which Shirodkar or McDonald cerclage has previously failed or is not technically feasible, TACIC offers the possibility of a successful outcome in elective and emergency settings similar to that previously reported for vaginal cerclage.     

腹腔镜宫颈环扎术的围手术期护理

目的:探讨孕前及早孕期腹腔镜宫颈环扎术的围手术期护理方法。方法:选择2013年7月—2015年12月于首都医科大学附属复兴医院宫腔镜中心因宫颈机能不全不育行孕前及早孕期腹腔镜宫颈环扎术的患者331例,围手术期护理包括:术前的心理疏导、完善术前准备及手术前后的交接,术后严密观察病情、用药护理及进行活动指导,出院时做好健康宣教,告知注意事项。结果:311例孕前患者实施腹腔镜宫颈环扎术,术后妊娠216例,其中187例妊娠29~39周剖宫产分娩,早产35例,共娩出191个活婴(双胎4例);21例正在妊娠中;8例于孕中期流产。20例早孕期手术患者实施腹腔镜宫颈环扎术,术后2例超声确认胎儿停止发育行清宫术(其中1例辅助生殖为双胎),18例妊娠36~39周剖宫产分娩,共娩出19个活婴(双胎1例)。结论:腹腔镜宫颈环扎术可有效预防宫颈机能不全引起的流产或早产,加强围手术期护理,有利于提高手术的效果,达到改善妊娠结局的目的。     

Zervixinsuffizienz: operative Möglichkeiten

In recent years, the incidence of operations at the uterine cervix to prevent miscarriages and preterm deliveries has declined steadily. In Berlin, the rate is now well below 1% of all pregnancies. Obviously, the cause lies in the indication and not the operation itself. The operations are based on two premises: (1) a cerclage can prevent premature opening of the cervix due to cervical incompetence and (2) operative occlusion of the cervical canal can prevent transcervical infections following incomplete mucous sealing of the cervical canal or as a consequence of cervical lacerations. Cervical incompetence in the classical sense is an extremely rare finding. In women deemed to be at increased risk of cervical incompetence, cerclage was not found to prolong pregnancy significantly. It is still unclear whether cervical cerclage can improve outcomes in pregnancies with decreased cervical length or dilation of the internal os as detected by vaginal ultrasound. Indications and outcomes of the rare cervix occlusion operations have not as yet been studied in prospective randomized trials. In spite of this, some results suggest that women with a history of repeated miscarriages caused by ascending infections due to sealing deficits of the cervical canal may profit from an operation.     

双胎妊娠两次经阴道宫颈环扎成功分娩一例并文献复习

宫颈机能不全是导致妊娠晚期反复流产和早产的主要原因之一。早产可增加围生期发病率与死亡率,给妊娠妇女及家庭带来严重心理和经济负担。目前在国内外,宫颈环扎术被推荐使用于单胎妊娠,对其在双胎妊娠中的应用报道较少,指征不明确。回顾分析1例双胎妊娠经2次宫颈环扎术获2名健康活婴的病例资料并进行文献复习,探讨宫颈环扎术在双胎妊娠中的应用。