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。     

The effect of second trimester emergency cervical cerclage on perinatal outcome

Objective: To evaluate the effectiveness of emergency cervical cerclage and to determine predictors of failure or success in women with cervical incompetence. Methods: Medical records were reviewed for clinical and demographic data, gestational age at time of cerclage, cerclage–delivery interval, gestational age at time of delivery; and birth weight. Predictors of success and failure were analyzed. Result: Forty-three pregnant women between 18 and 25 weeks of gestation were recruited. The mean gestational age at time of cerclage was 21 weeks. The mean cerclage–delivery interval was 64 days. The mean gestation at delivery was 31 weeks and the mean neonatal birth weight was 2166 g. Whether cerclage done before or after 20 weeks, the difference in cerclage–delivery interval was insignificant while the difference in gestational age at time of delivery and neonatal birth weight was significant. Presence of infection, presence of symptoms, membranes through the cervix and dilated cervix >3 cm are frequently associated with failure. Conclusion: Emergency cervical cerclage is effective in prolonging pregnancy and improving neonatal outcome in patient with cervical incompetence. However, large prospective randomized controlled studies are recommended.     

The prevalence and timing of cervical cerclage placement in multiple gestations.

OBJECTIVES: To investigate the prevalence and timing of cervical cerclage placement in multiple gestations. METHODS: Our perinatal database was queried for all multiple gestations delivered at Evanston Hospital from 12/95 through 12/00. This list was then cross-matched with billing and medical records for 'incompetent cervix' and 'cerclage.' The medical records of all deliveries /=14 weeks over a 5-year period. The number of patients that underwent cerclage placement was 29 or 3.6%. The mean gestational age at cerclage placement was 18.6+/-4.5 weeks (range 11-24.6). Twelve were elective or prophylactic while 17 were 'urgent' or 'emergent.' The mean gestational age for the 17 emergent cerclages was 21.4+/-2.2 weeks (range 16.6-24.6). When compared with those patients who did not undergo cerclage placement, there was no difference in maternal demographics including age, parity, or previous full-term delivery. There was a significant difference in the gestational age at delivery for the cerclage vs. no cerclage group; 29.3+/-5.6 vs. 34.4+/-4.6 weeks, respectively, and in the frequency of losses at 相似文献   

孕前“极简式”腹腔镜下宫颈环扎术的临床应用

目的:探讨"极简式"腹腔镜下宫颈环扎术(simplified laparoscopic cervical cerclage,SLCC)预防既往经阴道宫颈环扎失败的女性中期流产、早产的效果,并评价手术安全性。方法:分析2010年12月—2015年8月首都医科大学附属复兴医院收治的153例有经阴道宫颈环扎术失败史,实施孕前SLCC的患者临床资料。患者术前孕中期流产平均次数为(2.7±1.2)次,孕周为13~27周,平均孕周(20.0±3.5)周。结果:153例SLCC患者手术顺利,平均手术时间(33.0±1.3)min,术中平均出血量(9.7±8.3)m L,无严重手术并发症。术后共117例患者妊娠,其中8例妊娠2次,总妊娠次数125次;其中包括20次早期流产,2次异位妊娠,1次葡萄胎;截至2015年8月,正在妊娠中19例,已知妊娠结局83例,活产率为96.4%(80/83),平均终止妊娠孕周为(37.2±2.2)周。结论:对于既往经阴道宫颈环扎失败的宫颈机能不全患者,SLCC是一种简单、安全、有效的治疗方法。     

Cervical incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone

OBJECTIVE: The purpose of this study was to compare preterm delivery rates and neonatal morbidity/mortality rates for women with cervical incompetence with membranes at or beyond a dilated external cervical os that was treated with emergency cerclage, bed rest plus indomethacin, versus just bed rest. STUDY DESIGN: Women with cervical incompetence with membranes at or beyond a dilated external cervical os, before 27 weeks of gestation, were treated with antibiotics and bed rest and randomly assigned for emergency cerclage and indomethacin or bed rest only. RESULTS: Twenty-three women were included; 13 women were allocated randomly to the emergency cerclage and indomethacin group, and 10 women were allocated randomly to the bed rest-only group. Gestational age at time of randomization was 22.2 weeks in the emergency cerclage and indomethacin group and 23.0 weeks in the bed rest-only group. Mean interval from randomization until delivery was 54 days in the emergency cerclage and indomethacin group and 20 days in the bed rest-only group (P=.046). Mean gestational age at delivery was 29.9 weeks in the emergency cerclage and indomethacin group and 25.9 weeks in the bed rest-only group. Preterm delivery before 34 weeks of gestation was significantly lower in the emergency cerclage and indomethacin group, with 7 of 13 deliveries versus all 10 deliveries in the bed rest-only group (P=.02). CONCLUSIONS: Emergency cerclage, indomethacin, antibiotics, and bed rest reduce preterm delivery before 34 weeks compared with bed rest and antibiotics alone.     

Effectiveness of emergency cerclage in cervical insufficiency

Objective: To assess the effectiveness of emergency cerclage versus conservative management in improving obstetric and neonatal outcomes in women with clinically evident cervical insufficiency.

Methods: Retrospective cohort study conducted on all women with a single viable pregnancy diagnosed with cervical insufficiency between the 14th and 24th gestational week without pPROM, clinical chorioamnionitis, vaginal bleeding, treatment-resistant uterine contractions or life-incompatible fetal anomalies, from January 2009 to December 2014. Obstetric and neonatal outcomes were compared between women who underwent cerclage and those who refused, preferring a conservative therapy.

Results: Eighteen women underwent emergency cerclage and 19 were managed with a conservative therapy. Mean gestational age at delivery, time from diagnosis to delivery and rate of term birth were significantly higher in the first cohort. Those variables show a linear inverse correlation with the degree of cervical dilatation, with better outcomes in patients who underwent cerclage with a dilatation lower than 5.0 cm. No difference in mode of delivery were found.

Conclusion: Emergency cerclage is a valid therapeutic option between the 14th and 24th gestational week in presence of cervical insufficiency when signs of premature labour or infection are not present, with lower expectations with a dilatation greater than 5 cm.     

Obstetrical outcomes of emergency compared with elective cervical cerclage

Objective: To study obstetric outcomes of emergency cerclage compared with elective cerclage.

Study design: Retrospective cohort study of pregnancy outcomes of patients who underwent cervical cerclage, performed according to ACOG guidelines, between January 2006 and December 2014. Patients who underwent emergency cerclage, due to cervical shortening or cervical dilation (emergency cerclage group) were compared with patients who underwent history-indicated cerclage (elective cerclage group). Emergency cerclage was not performed in patients with uterine contractions, vaginal bleeding, or signs of chorioamnionitis. Procedure-related complications were defined as rupture of membranes or chorioamnionitis occurring after cerclage placement and before 24 weeks of gestation.

Results: Overall, 154 patients with elective cerclage and 47 patients with emergency cerclage were included. Mean gestational age at cerclage operation was 13.1?±?1 and 20.2?±?3 weeks, respectively. There were no differences between the emergency cerclage group and the elective cerclage group regarding mean gestational age at delivery (36.1?±?3 versus 35.6?±?3, respectively, p?=?0.7), rate of deliveries beyond 34 weeks of gestation (81.81% versus 78.72%, respectively, p?=?0.67), rate of deliveries beyond 37 weeks of gestation (64.93% versus 59.57%, respectively, p?=?0.6), cesarean deliveries (33.11% versus 39.13%, p?=?0.48, respectively), or birthweight (2848 versus 2862 grams, respectively, p?=?0.9). Regarding procedure-related complications, there were no differences between the elective and the emergency cerclage groups in the rate of chorioamnionitis (1.29% versus 4.34%, respectively, p?=?0.22), or ruptured membranes (1.29% versus 4.34%, respectively, p?=?0.22).

Conclusion: Pregnancy outcomes of emergency cerclage are comparable with those of elective cerclage.     

Transabdominal cervico-isthmic cerclage in the management of cervical incompetence in high risk women

Objectives

Transabdominal cervico-isthmic cerclage is an alternative to vaginal route for patients with severe cervical incompetence. The purpose of this study is to describe our experience with this technique during pregnancy for high risk women.

Materials and methods

We performed a retrospective study including 12 transabdominal cerclages performed between 1988 and 2005. All patients had an history of repeated midtrimester fetal losses or preterm delivery, and 82% already had a prior failed transvaginal cerclage. Fourteen pregnancies were reported.

Results

The median gestational age at cerclage placement was 14 weeks (range: 12 to 17). All patients underwent a caesarean section at a mean gestational age of 35 weeks gestation (range: 23 to 38 WG). The fetal survival rate was 93 compared to 17% before the cerclage. There were no significant perioperative or neonatal complications.

Conclusion

Transabdominal cervico-isthmic cerclage remains a reliable technique for the management of cervical incompetence after a prior failed transvaginal cerclage when vaginal access is difficult. Laparoscopic approach is under development.     

Cervical dilation as a predictor of pregnancy outcome following emergency cerclage

Objective: To determine whether cervical dilation at the time of physical examination indicated cerclage placement can predicts latency and gestational age at delivery. Methods: A retrospective cohort study of all women who underwent physical examination indicated cerclage placement from 1996 to 2011 at Duke University Hospital (DUH) was performed. Physical examination indicated cerclage was defined as cerclage placement after 16 weeks in women with a cervical length of less than 2.5?cm and/or cervical dilation greater than or equal to 1?cm at time of procedure. Subjects were divided into two groups depending on cervical dilation at time of procedure (≥2?cm, <2?cm) for comparison. A multivariate linear regression model for the outcome gestational age of delivery was constructed, controlling for confounding variables. Results: A total of 110 women with complete data were available for analysis. Median gestational age at cerclage placement was similar between the two groups (20.3 vs. 20.3 weeks, p?=?0.8). Women with cervical dilatation ≥2?cm dilation delivered at an earlier median gestational age than women with cervical dilation <2?cm (27.0 vs. 35.6 weeks, p < 0.001). Cervical dilation at the time of cerclage placement independently predicted gestational age at delivery while controlling for use of intracervical Foley balloon catheter for membrane reduction, cerclage suture type, history of prior preterm birth, race, insurance status, and tobacco use. Conclusions: Women who receive a rescue cerclage are more likely to deliver at an earlier gestational age when cervical dilation is ≥2?cm at the time of procedure.     

A simple scoring system for the treatment of cervical incompetence diagnosed during the second trimester

Twenty-four women with second-trimester cervical incompetence underwent emergency cerclage. The appropriateness of cervical cerclage was analyzed according to a scoring system (Cervical Incompetence Scale; CIS) which measures the degree of cervical effacement, cervical dilatation and protrusion of fetal membranes into the cervical canal. Patients with low CIS (0-3 points) were found to have a more favorable pregnancy outcome than patients with high-score cervical incompetence (5-8 points), i.e. fewer complications following the procedure, 33.3 and 87.5%, respectively, fewer pregnancy losses (22.2 and 75%, respectively) and a significantly prolonged postoperative pregnancy course (mean gestation 33.2 and 24.4 weeks at delivery, respectively). The chances of a successful pregnancy outcome were evaluated at 87.5%; the outcome was successful in patients with low CIS presenting with effacement of the uterine cervix of less than 50%, cervical dilatation of less than 1.5 cm and with fetal membranes remaining in the cervical canal. On the basis of these results, we conclude that the emergency cerclage operation in carefully selected patients with midtrimester cervical incompetence may improve the outcome of pregnancy. This selection is facilitated by the use of a new cervical incompetence scoring system described herein.     

腹腔镜下子宫峡部环扎术

子宫峡部环扎术是治疗宫颈机能不全最主要的方法。对于反复经阴道环扎失败或宫颈解剖异常不能经阴道环扎的患者,可选择经腹腔镜子宫峡部环扎。腹腔镜子宫峡部环扎术可在非孕期或早孕期进行。孕中晚期发生胎儿异常需终止妊娠时可经剖腹或腹腔镜拆除缝线经后阴道分娩。足月妊娠则需要剖宫产终止妊娠。腹腔镜下子宫峡部环扎术是治疗宫颈机能不全的有效方法之一,但其是否能作为治疗宫颈机能不全的标准术式尚待多中心临床随机对照研究结果证实。     

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.     

紧急宫颈环扎术联合网片补丁缝合治疗宫颈机能不全32例临床分析

目的:探讨紧急宫颈环扎术联合网片补丁缝合治疗宫颈机能不全的临床价值。方法:选取2011年1月至2016年8月我院宫颈机能不全孕妇65例,32例施行紧急宫颈环扎联合网片补丁缝合术(A组),33例仅实施紧急宫颈环扎术(B组),对两组延长妊娠的时间、分娩孕周、新生儿结局、分娩方式及术后相关并发症进行比较。结果:A组手术时间长于B组,手术并发症宫颈裂伤A组少于B组,差异均有统计学意义(P0.05);术后两组绒毛膜羊膜炎的发生率差异无统计学意义(P0.05);A组延长孕周84.45±35.77天,B组延长孕周51.86±29.93天,两组比较差异有统计学意义(P0.05);A组≥28周分娩23例(71.88%),B组≥28周分娩17例(51.52%),两组比较差异有统计学意义(P0.05);两组分娩方式比较,差异无统计学意义(P0.05);B组的新生儿出生体质量、出生时Apgar 1分钟评分均低于A组,差异均有统计学意义(P0.05)。结论:紧急宫颈环扎术联合网片补丁缝合能有效延长宫颈机能不全患者的孕周,明显改善新生儿结局,安全性较好,有一定临床应用价值。     

减胎术联合宫颈环扎术治疗多胎妊娠并宫颈机能不全2例临床分析

多胎妊娠、宫颈机能不全等均是流产或早产的高危因素,若多胎妊娠患者合并宫颈机能不全则流产或早产的风险更高。现报道2例多胎妊娠合并宫颈机能不全患者,分别在孕11+5周和20+5周行减胎术,随后分别在13+4周和21+6周行宫颈环扎术,定期产检阴道超声监测宫颈长度并及时预防早产治疗,分别在孕36周和孕33+4周成功顺产活婴,认为减胎术是多胎妊娠改善妊娠结局的补救措施,减胎术后行宫颈环扎术可修复宫颈的机能,而定期随访对防治早产、指导临床用药及适时拆除宫颈环扎线并改善母儿预后至关重要。当多胎妊娠合并宫颈机能不全时,采用减胎术联合宫颈环扎术进行治疗是一个可供临床借鉴的选择方案。     

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.     

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。     

Cervical incompetence: diagnosis and outcome

The results of 147 cervical cerclage procedures were reviewed in a retrospective study. Patient history and past reproductive performance were assessed to determine which factors were predictive of successful pregnancy outcome after cervical cerclage. A past history of spontaneous second trimester abortion or premature labor was associated with a better outcome than was a history classically associated with cervical incompetence. Morbidity immediately following the procedure was low, however significant morbidity related to cervical scarring occurred at the time of delivery. There was poor correlation between the clinical history, examination and adjunctive tests of cervical incompetence, and the pregnancy outcome following cerclage. These observations indicate the need for a prospective, randomized study of the efficacy of this procedure.     

Cervical incompetence: the use of selective and emergency cerclage

OBJECTIVE: This prospective case series was performed in order to assess pregnancy outcome of women with tentative diagnosis of cervical incompetence undergoing selective and emergency cervical cerclage. METHODS: Women recruited in this case series were divided into two groups. The selective group (n = 13) was chosen among pregnant women with a history suggestive of cervical incompetence, but no clinical evidence of threatened miscarriage. The definition of cervical incompetence was dilatation of internal cervical os with shortening of the cervix less than 25 mm and "funnelling" of 25% and more, found on the ultrasound examination of the cervix. The emergency group (n = 12) had clinical symptoms of threatened miscarriage. After exclusion of infection and in the absence of uterine activity they were counseled and offered cerclage. RESULTS: After cervical cerclage all women were treated in the same way as per our clinical protocol and monitored until delivery. The median gestational age at delivery was 36 weeks (19-39) in the selective group and 33 weeks (22-38) in the emergency group. This difference is not statistically significant. There was 1 miscarriage (8%), 5 pre-term deliveries (38%) and 7 term deliveries (54%) in the selective group; and 4 miscarriages (33%), 3 pre-term deliveries (25%) and 5 term deliveries (42%) in the emergency group. Total neonatal survival was 19/20 (95%) if pregnancy exceeded 24 weeks, making perinatal mortality 5%. There was no differences between selective and emergency groups (1 of 12 in selective vs. 0 of 8 in emergency). CONCLUSION: Overall, it can be concluded that both selective and emergency cerclage may have some benefits in patients with cervical incompetence. However, in the absence of a randomized-controlled study, these beneficial effects described cannot be considered as proved.     

Emergency cervical cerclage: effect on pregnancy outcome and mode of delivery

Abstract

Aim: To evaluate the effectiveness of emergency cervical cerclage (ECC) and its effect on the mode of delivery.

Patients and methods: Between April 2007 and July 2011 patients attending MH Diyarbakir Obstetrics and Gynecology Hospital and MH Seferihisar State Necat Hepkon Hospital who underwent ECC were included in this retrospective analysis.

Results: At the time of ECC, the mean gestational age, cervical length and cervical dilatation were 21.4?±?2.2 weeks, 4.3?±?0.8?cm and 11?±?2.4?mm, respectively. The average time between the procedure and birth was 13.8?±?4.9 weeks and this period was sufficient to maintain a viable pregnancy (p?<?0.05). In this study, 12 patients (60%) were delivered vaginally and eight (40%) patients delivered with CS (40%). the difference was statistically insignificant (p?=?0.371). Regarding the gestational age at time of delivery, 55% of patients delivered at 36 weeks, 70% at 32 weeks, and 80% of them delivered at 28 weeks. The total live birth rate was 90%.

Conclusion: ECC provides satisfactory time for the fetus to gain sufficient viability. Pregnancies with emergency cerclage show no difference in terms of birth method, whether cesarean or vaginal birth, and delivery type does not appears to be linked to ECC.     

Cervical surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence

OBJECTIVE: The aim of the present study was to compare the outcome of pregnancies among patients with suspected cervical incompetence treated either by elective cervical cerclage or an alternative management program involving cervical surveillance. DESIGN, SETTING AND METHODS: A prospective cohort study was performed in two groups of patients at risk of cervical incompetence with singleton gestations attending the Royal Women's Hospital, Melbourne, Australia, from 1996 to 2000. The first group was managed by their obstetric carers with an elective cerclage, while the second group was managed conservatively as part of a cervical surveillance program offered to patients attending the Department of Perinatal Medicine for pregnancy care. This program consists of weekly visits from 16 weeks' gestation and involves alternating transvaginal ultrasound assessment of cervical morphometry with cervico-vaginal bacteriology and fetal fibronectin swabs. Empiric insertion of a cerclage is undertaken when there is evidence of significant cervical shortening (cervical canal <2.5 cm in length at 相似文献