疑似宫颈机能不全的保守治疗

摘要/Abstract

摘要：

超声检测宫颈长度可以辅助诊断宫颈机能不全，但是无统一标准，妊娠中期渐进性无痛性宫颈扩张或缩短为可疑宫颈机能不全, 同时伴有早产史或晚期流产史者更符合宫颈机能不全。妊娠中期宫颈长度<25 mm早产风险显著增加，为可疑宫颈机能不全。对于无早产史或晚期流产史者孕妇行环扎术无显著降低早产率的证据，但宫颈长度≤20 mm应用孕酮显著减少了不同孕周的早产率，显著改善了围产儿的结局。对于有早产史或晚期流产史伴宫颈长度<25mm者应用孕酮、环扎和宫颈托均有益处，可据患者意愿和医生的经验选择个体化处理方案。

关键词: 宫颈机能不全, 宫颈长度缩短, 孕酮, 环扎术, 宫颈托 

Abstract:

Abstract:A widely agreed-upon definition for the diagnosis of cervical insufficiency has yet to be achieved. The advent of ultrasonic cervical length measurement has added an additional criterion to the definition of cervical insufficiency. During the midtrimester of pregnancy the cervical length shorter than 25 mm by vaginal sonography without uterine contraction is suspicious of cervical insufficiency. Cerclage indicated by ultrasound for women with singleton gestations, no prior preterm birth history is no significant benefit for reduction of the preterm birth rate, however vaginal progesterone, either 90-mg gel or 200-mg suppository, is associated with reduction in PTB and perinatal morbidity and mortality when the CL<20mm. Either vaginal progesterone or cerclage or cervical pessary are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the midtrimester, singleton gestation, and previous preterm birth history. The selection of the optimal treatment may depend upon adverse events, cost and patient/clinician preferences.

Key words: cervical insufficiency, short cervical length, progesterone, cerclage, cervical pessary

中图分类号:

R711.74

时春艳. 疑似宫颈机能不全的保守治疗[J]. 中国实用妇科与产科杂志.

SHI Chun-yan. . Conservative treatment for suspicious cervical insufficiency. [J]. Acta Metallurgica Sinica.

参考文献



[1］ ACOG, American College of Obstericians and Gynecologists. Practice Bulletin. Cervical Insufficiency［J］. Obstet Gynecol,2003,102:1091-1099.

[2］ Berghella V, Odibo AO, Tolosa JE. Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound: a randomized trial［J］. Am J Obstet Gynecol,2004,191:1311-1317.

[3］ To MS, Alfirevic Z, Heath VCF, et al. Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial［J］. Lancet, 2004,363:1849-1853.

[4］ Berghella V,Keeler M, TO MS, et al. Effectiveness of cerclage according to severity of cervical length shortening: a meta-analysis［J］. Ultrasound Obstet Gynecol,2010,35:468-473.

[5］ Fonseca EB, Celik E, Parra M, et al. Progesterone and the risk of preterm birth among women with a short cervix［J］. N Engl J Med,2007,357:462-469. 

[6］ Rai P, Rajaram S, Goel N, et al. Oral micronized progesterone for prevention of preterm birth［J］. Int J Gynaecol Obstet,2009,104:40-43. 

[7］ Glover MM, McKenna DS, Downing CM, et al. A randomized trial of micronized progesterone for the prevention of recurrent preterm birth［J］. Am J Perinatol,2011,28:377-381.

[8］ Hassan SS， Romero R, Vidyadhari D. et al. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial［J］. Ultrasound Obstet Gynecol, 2011,38:18-31.

[9］ Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and meta-analysis of individual patient data［J］. Am J Obstet Gynecol,2012, 206: 124, e1-19.

[10］ Sotiriadis A, Papatheodorou S, Makrydimas G. Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis［J］. Ultrasound Obstet Gynecol,2012,40:257-266. 

[11］ Society for Maternal-Fetal Medicine (SMFM) Publications Committee,with the assistance of Vincenzo Berghella.Progesterone and preterm birth prevention: Translating clinical trials data into clinical practice［J］. Am J Obstet Gynecol, 2012,206:376-386.

[12］ Berghella V, Baxter1 JK, Hendrix NW. Cervical assessment by ultrasound for preventing preterm delivery［J］.Cochrane Database Syst Rev,2013,1:CD007235. 

[13］曲首辉，时春艳.孕中、晚期孕妇子宫颈长度测量对早产的预测［J］.中华妇产科杂志，2011,46：748-751.

[14］ Owen J, Hankins G, Iams JD, et al. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length［J］. Am J Obstet Gynecol,2009,201:375.e1-8.

[15］ Berghella V, Rafael TJ, Szychowskiet JM, et al. Cerclage for Short Cervix on Ultrasonography in Women With Singleton Gestations and Previous Preterm Birth: A Meta-Analysis［J］. Obstet Gynecol,2011,117:663-671.

[16］ Campbell S. Universal cervical-length screening and vaginal progesterone prevents early preterm births, reduces neonatal morbidity and is cost saving: doing nothing is no longer an option［J］. Ultrasound Obstet Gynecol,2011, 38:1-9.

[17］时春艳,王建,金燕志,等. 宫颈机能不全的早期超声诊断和治疗［J］.中国医刊，2008，43: 61-63.

[18］ Conde-agudelo A, Romero R, Nicolaides K, et al. Vaginal progesterone versus cervical cercalge for the prevention of preterm birth in women with a sonographic short cervix, singleton gestation,and previous preterm birth: A systematic review and indirect comparison meta-analysis［J］. Am J Obstet Gynecol,2013,208: e1-18.

[19］ Word RA, Li XH, Hnat M, et al. Dynamics of cervical remodeling during pregnancy and parturition: mechanisms and current concepts［J］. Semin Reprod Med, 2007,25: 69-79.

[20］ O'Brien JM, DeFranco EA, Adair CD, et al. Progesterone Vaginal Gel Study Group. Effect of progesterone on cervical shortening in women at risk for preterm birth: secondary analysis from a multinational, randomized, double-blind, placebo-controlled trial［J］. Ultrasound Obstet Gynecol,2009, 34: 653-659.

[21］ Mesiano S,Welsh T. Progesterone and the control of human pregnancy and parturition［J］. Fetal Maternal Medicine Review,2009,20:97-118.

[22］ Roberson AE, Hyatt K, Kenkel C, et al. Interleukin-1 beta regulates progesterone metabolism in human cervical fibroblasts［J］. Reprod Sci,2012, 19:271-281. 

[23］ Yellon SM, Ebner CA, Sugimoto Y. Parturition and recruitment of macrophages in cervix of mice lacking the prostaglandin F receptor［J］. Biol Reprod,2008, 78:438-444. 

[24］ Goya M, Pratcorona L, Merced C, et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial［J］. Lancet, 2012,379:1800-1806.

[25］ Alfirevic Z, Owen J, Carreras E, et al. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix［J］. Ultrasound Obstet Gynecol,2013, 41: 146-151.

[26］ Hui SY, Chor CM, Lau TK, et al. Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial［J］. Am J Perinatol, 2013,30:283-288.

[27］ Liem SM, van Pampus MG, Mol BW, et al. Cervical pessaries for the prevention of preterm birth: a systematic review［J］. Obstet Gynecol Int, 2013,Published online 2013 March 31.

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