不同妊娠期经阴道子宫颈环扎术后妊娠结局分析

目的 探讨妊娠期不同经阴道宫颈环扎手术方式患者母儿结局及相关因素。方法 选取2013年1月至2021年9月就诊于北京大学人民医院产科因妊娠期宫颈机能不全行宫颈环扎术的69例患者,其中行Shirodkar宫颈环扎手术37例作为研究组;行Mc Donald宫颈环扎手术32例作为对照组。比较两组的临床特点及妊娠结局差异。结果 研究组与对照组比较,妊娠期体质量增加较大[(12.66±6.00) kg/m²,(9.21±5.79) kg/m²;P=0.022]、手术时间长[47 min (41～60 min), 20.5 min (17～37.5 min); P <0.001]、拆线孕周晚[36.71周(36.14～37周),34.43周(24.32～36.75周), P=0.003],分娩孕周大[38.9周(36.3～39.8周),35.0周(30.1～39.0周),P=0.005],妊娠≥28周(91.9%, 68.8%, P=0.028)、≥34周(81.1%, 59.4%, P=0.036)、≥37周(67.6%, 37.5%, P=0....     

非妊娠期环扎带宫颈环扎术2例报告及文献复习

目的:探讨非妊娠期环扎带宫颈环扎术的有效性和可行性.方法:例1患者因发现宫颈松弛,于妊娠21周行经阴道宫颈环扎术,妊娠23周因难免流产行第2次经阴道官颈环扎术失败,于非妊娠期行环扎带宫颈环扎术.例2患者因宫颈功能不全中期妊娠流产5次,于非妊娠期行腹腔镜环扎带宫颈环扎术.手术经过均顺利.结果:例1于术后1年零3个月,妊娠...     

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。     

宫颈环扎术在防治流产和早产中的应用

早产是造成新生儿发病和死亡的主要原因,而宫颈功能不全是造成晚期流产、早产的主要疾患之一。宫颈功能不全又名宫颈机能不全,是指妊娠后,在达到足月妊娠前宫颈展平、变薄,宫颈管扩张、变宽的临床状态,最终导致中期妊娠流产或早产。在欧洲和其他发展中国家,早产的发生率为5%~9%,在某些国家,这一现象仍有增长趋势,几乎没有什么有效措施可以改善这种结局,而且对现代产科来说,其管理仍是一种挑战。宫颈环扎是目前产科常用的预防流产和早产的干预和管理措施,但缺乏有效的证据证实其益处,宫颈环扎的效果也不确定,现就妊娠中期宫颈功能的评定以及实施宫颈环扎术的指征加以论述。     

宫颈缩短和自发性早产诊治进展

早产是产科最常见的并发症之一,是全球公认的重大公共卫生问题,可造成严重的母儿并发症甚至死胎等严重不良结局。早产的致病因素复杂,病理生理机制多样,但宫颈缩短是自发性早产的必经过程。因此,预防和延缓宫颈缩短是预防早产的重点。本文通过指南学习和相关临床研究的系统性回顾,围绕宫颈缩短和自发性早产的病因、发生机制及治疗开展讨论,对目前宫颈缩短和自发性早产的临床研究进展进行综述。     

改良阴式子宫峡部环扎术的应用

宫颈机能不全是导致中晚期流产和早产的重要原因,宫颈环扎术作为治疗宫颈机能不全的主要手段广泛应用于临床,经阴道子宫峡部环扎手术操作简便、有效,同时避免了经腹环扎术需再进腹拆线的弊端。本文就经阴道子宫峡部环扎术适应证、手术操作、手术时机及并发症进行相关阐述。     

腹腔镜下经腹宫颈环扎术:孕11周宫颈阴道段消失一例报道

正宫颈机能不全占全部妊娠的0.5%~1.0%,且复发率为30%~([1])。患者常于孕早、中期发生无宫缩的胎膜早破,而出现典型的骨盆受压和宫颈扩张。由于先天因素或既往行宫颈手术史而出现宫颈结构严重变异,无法行经阴道宫颈环扎术的患者,可采取经腹宫颈环扎术。该文作者提出了腹腔镜下宫颈环扎术的一些经验。     

宫颈环扎术的术后妊娠期管理

宫颈环扎术作为预防宫颈机能不全所致早产的治疗手段之一,已广泛用于临床,对于其术后患者是否需在围手术期使用抗生素和保胎药物、终止妊娠的时机和方式及遗留缝线的处理等问题值得临床医生关注和讨论。本文复习国内外文献及江南大学附属医院妇产科的临床经验就宫颈环扎术后妊娠期管理的一些重要问题进行初步探讨。     

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。     

病史指征宫颈环扎术后宫颈长度变化与<34周早产的研究

目的探讨在病史指征的宫颈环扎术人群中超声监测宫颈长度(cervical length, CL)的变化及环扎术后<24周短宫颈(CL≤2.5 cm)对<34周早产的预测价值。方法回顾性收集2010年1月至2021年6月在北京大学第一医院行病史指征McDonald宫颈环扎术且资料完整的单胎孕妇共145例的临床资料, 记录在围手术期及环扎术后孕≥20～24、≥24～28、≥28～32周经阴道超声测量的闭合段CL, 按分娩孕周分为≥34周分娩组(n=118)和<34周分娩组(n=27), 分析2组环扎术后CL与<34周早产的关系及环扎术后孕≥20～24周短宫颈孕妇早产的风险。采用χ2检验或独立样本t检验进行组间比较, 采用多因素logistic回归分析2组的CL与<34周早产的关系, 并利用受试者工作特征曲线分析环扎术后CL对妊娠结局的预测价值。结果 (1)在145例病例中, 足月分娩106例(73.1%), <34周早产27例(18.6%), 其中7例(4.8%)<28周分娩(晚期流产)(其中2例为有生机儿并存活), 总体活产率96.6%(140/1...     

Comparison of two cervical cerclages for the prevention of preterm birth and neonatal complications

Objective: To investigate the outcomes of singleton pregnant women with cervical insufficiency undergoing two different cervical cerclages.

Methods: This is a retrospective cohort study of women who underwent a history- or ultrasound-indicated cerclage (either Shirodkar or McDonald) at a tertiary referral center from 2002 to 2014. Outcome parameters (delivery age, postoperative cervical length, preterm premature rupture of membranes, preterm delivery rate and neonatal complications) were compared between the two cerclage procedures. Multivariate logistic regression analysis was applied to control for significant variables of preterm birth. Kaplan–Meier survival analysis was used to demonstrate delivery age to percentage of term delivery by cerclage type.

Results: Ninety-four cases were initially included. After excluding cases not meeting the study criteria, 60 pregnancies (Shirodkar 36 and McDonald 24) were recruited for analysis. The mean delivery age in the Shirodkar group was more advanced than that in the McDonald group (37.1?±?3.3 versus 34.8?±?4.9 weeks, p?=?0.039). There were significantly fewer deliveries <37 gestational weeks in the Shirodkar group than in the McDonald group (30.6% versus 58.3%, p?=?0.033) but no significant differences in deliveries <28, 32 and 34 gestational weeks. No significant differences were found in neonatal complications except for respiratory distress syndrome (5.6% in Shirodkar versus 29.2% in McDonald, p?=?0.023).

Conclusion: In the setting of history-indicated or ultrasound-indicated cerclage, Shirodkar was superior to McDonald in the prevention of late preterm birth and neonatal respiratory distress syndrome.     

McDonald versus Shirodkar cervical cerclage for the prevention of preterm birth: impact of body mass index

Objective: To compare obstetrical outcomes on women undergoing a McDonald or Shirodkar cerclage and to estimate the impact of maternal body mass index (BMI) on these outcomes.

Methods: We conducted a retrospective review of the medical records of all women with singleton pregnancies who underwent placement of a McDonald or Shirodkar cerclage at St. Francis Hospital from January 2008 to October 2013. The subjects were categorized based on BMI groups (normal: less than 25?kg/m², overweight: 25–29?kg/m², obese: 30?kg/m² or more). The primary outcome was gestational age at delivery. Statistical analyses included chi-square, Student’s t-test, and multivariable regression analysis.

Results: Of 95 women, 47 (49.5%) received a Shirodkar, and 48 (50.5%) a McDonald cerclage. 16 women (16.8%) were categorized as normal weight, 35 (36.8%) as overweight, and 44 (46.3%) as obese. Gestational age at delivery differed significantly by group, decreasing with each categorical increase in BMI (normal: 39.0?±?0.3 weeks; overweight: 36.6?±?0.7 weeks; obese: 33.0?±?1.1 weeks; p?p?=?.02). However, analysis showed a significant interaction between weight status and gestational age at delivery. Obese women had significantly longer pregnancies when they received a Shirodkar cerclage versus a McDonald cerclage (32.6?±?1.0 weeks versus 28.8?±?0.9 weeks; p?p?=?.63).

Conclusions: Compared to obese women receiving a McDonald cerclage, obese women receiving a Shirodkar cerclage had significantly longer pregnancies. No significant differences in pregnancy duration were found in normal/overweight women regardless of cerclage technique. Pregnancy duration in obese women receiving a Shirodkar cerclage was similar to the pregnancy duration of normal/overweight women.     

Ultrasound-indicated cerclage: Shirodkar vs. McDonald

Objective: To compare the efficacy of Shirodkar to McDonald cerclage in patients with singleton pregnancies undergoing an ultrasound-indicated cerclage. Methods: Historical cohort of all patients with singleton pregnancies undergoing cerclage for the indication of a short cervix on ultrasound (ultrasound indicated) at one institution in 2005–2010. We compared outcomes based on cerclage type, Shirodkar or McDonald. Outcome measures were gestational age (GA) at delivery, delivery ≥35 weeks, ≥32 weeks, and PPROM. Multivariable regression analysis was performed to control for significant variables. Results: Seventy-four patients with singleton pregnancies underwent an ultrasound-indicated cerclage in the study period (47 Shirodkar, 27 McDonald). Shirodkar was associated with later GA at delivery (mean GA at delivery 36.98 +/? 3.39 vs. 33.34 +/? 6.37 weeks, p = 0.006), a higher likelihood of delivering ≥35 weeks (83 vs. 55.6%, p = 0.011) and ≥32 weeks (91.5 vs. 59.3%, p = 0.001), and a lower likelihood of preterm premature rupture of membrane (PPROM) (13.0 vs. 46.2%, p = 0.002). On adjusted analysis controlling for differing baseline characteristics, Shirodkar remained significantly associated with an increased incidence of delivery ≥32 weeks (odds ratio [OR]: 5.180, 95% CI: 1.024–26.205). Conclusion: Compared to the McDonald technique, the Shirodkar technique was more effective in prolonging pregnancy in patients with singleton pregnancies undergoing ultrasound-indicated cerclage. A prospective trial is needed to compare these two techniques.     

单胎妊娠短子宫颈孕妇不同方式治疗后的临床结局及其影响因素分析

目的:探讨不同子宫颈长度、不同诊断孕周的单胎妊娠短子宫颈孕妇,接受不同方式治疗后妊娠结局的差异并分析其影响因素。方法:收集2018年1月1日至12月31日于北京大学第一医院妇产科产前检查,妊娠12~33周 +6超声检查诊断为短子宫颈（≤25 mm）的单胎妊娠孕妇435例的临床资料,进行回顾性队列分析。435...     

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   

Favorable outcome following emergency second trimester cerclage.

BACKGROUND: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. METHODS: A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. RESULTS: Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2). CONCLUSIONS: Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.     

Shirodkar versus McDonald cerclage for the prevention of preterm birth in women with short cervical length

The efficacy of Shirodkar cerclage was compared with that of the McDonald procedure for the prevention of preterm birth (PTB) in women with a short cervix. Secondary analysis using data from all published randomized trials including women with a short cervical length (CL) was performed comparing the use of Shirodkar versus McDonald sutures. Analysis was limited to singletons with short CL on transvaginal ultrasound. The primary outcome measure was PTB < 33 weeks. Statistical analysis was performed using bivariate and multivariable techniques. From 607 women randomly assigned in the study, 277 met our inclusion criteria; 127 received Shirodkar and 150 women received McDonald sutures. The mean ( +/- standard deviation) gestational age at delivery was 35.0 +/- 5.3 versus 36.3 +/- 4.7 for the Shirodkar versus McDonald groups, respectively ( p< 0.02). PTB < 33 weeks was seen in 61 (22%) of 277 women; 26 (20%) of 127 in the Shirodkar and 35 (23%) of 150 in the McDonald groups, respectively (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.5 to 1.6). On adjusting for confounders using logistic regression modeling, no significant difference in PTB < 33 weeks was found between the two groups (OR, 0.55; 95% CI, 0.2 to 1.3). In women with short cervical length randomly assigned to receiving cerclage, no significant difference in prevention of PTB was observed using Shirodkar or McDonald's procedures.     

Time interval from elective removal of cervical cerclage to onset of spontaneous labour

Objective

To determine the time interval between elective removal of a cervical cerclage to the onset of spontaneous labour in women who had either a history- or ultrasound-indicated cervical cerclage.

Study design

A retrospective cohort study of women with a singleton pregnancy that had either a modified Shirodkar or McDonald cervical cerclage inserted were evaluated for the time interval between elective cerclage removal and onset of spontaneous labour and also spontaneous labour with 72 h of cervical cerclage removal.

Results

Two hundred and sixty-nine singleton pregnancies with either a modified Shirodkar or McDonald cervical cerclage were analysed. The mean gestational age at cerclage removal was 36.7 ± 1.10 weeks and gestational age at spontaneous labour was 39.0 ± 1.94 weeks (mean ± SD). The median interval between cerclage removal and spontaneous labour was 14 days. Only 18% of women laboured spontaneously within 72 h. Women with ultrasound-indicated cerclage were more likely to deliver within 72 h, compared with women with a history-indicated cervical cerclage (odds ratio, 3.68; 95% confidence interval, 1.31–10.85, p = 0.01).

Conclusion

Independent of the indication or technique used for cervical cerclage, the rate of early spontaneous labour following elective removal of cervical cerclage is sufficiently low to justify outpatient management.     

Pregnancy outcomes and factors affecting the clinical effects of cervical cerclage when used for different indications: A retrospective study of 326 cases

ObjectiveTo compare pregnancy outcomes resulting from the use of cervical cerclage for different indications and investigate factors that might influence the clinical effects of cervical cerclage.Materials and methodsThis was a retrospective study of pregnant women who received cervical cerclage in The Women's Hospital, Zhejiang University School of Medicine, China. Patients were divided into three groups: a history-indicated group; an ultrasound-indicated group and a physical examination-indicated group. The pregnancy outcomes of the three groups were then compared. Univariate and multivariate logistic regression analysis were performed to assess the independent risk factors.ResultsStatistical differences were evident when the history-indicated group and the ultrasound-indicated group were compared with the physical examination-indicated group for gestational age at delivery [37.3(33.3–38.9), 35.4(28.9–38.4) vs. 26.1 (24.3–28.4) weeks, respectively, P < 0.05], percentage of cases delivered at < 28 weeks of gestation (13.4%, 20.3% vs. 74.3%, respectively, P < 0.05), percentage of cases delivered at < 37 weeks of gestation (42.7%, 54.2% vs. 91.4%, respectively, P < 0.05) and fetal survival rate (88.4%, 81.4% vs. 40.0%, respectively, P < 0.05). The history-indicated group and the ultrasound-indicated group were similar with regards to these outcomes. The independent risk factors affecting the clinical effects of cervical cerclage include age, body mass index (BMI), history of prior preterm birth and second-trimester loss, C-reactive protein (CRP) >5 mg/L and cervical dilation ≥3 cm (P < 0.05).ConclusionPregnancy outcomes were similar when compared between history-indicated and ultrasound-indicated cerclage. Serial cervical surveillance is beneficial for pregnant with a history of cervical insufficiency, and the placement of cervical cerclages in response to ultrasonographically detected shortening of the cervical length is a medically acceptable alternative to the use of history-indicated cerclage.