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目的评价应用改良的Shirodker手术的有效性和安全性。方法选择宫内孕14～15周,诊断宫颈机能不全,预行宫颈环扎手术的患者40人,随机分为观察组和对照组两组,每组各20例,观察组行改良的Shirodker手术,对照组行MeDonald宫颈环扎手术,比较两组术后妊娠结局和术后并发症。观察组手术方法:取膀胱截石位,常规消毒钳夹暴露宫颈,在膀胱反折水平切开宫颈前壁,将膀胱推至宫颈内口水平以上。相同方法在宫颈后方切开,将直肠和道格拉斯窝腹膜向上推至宫颈内口水平。余手术步骤同对照组,荷包缝合打结后前后切口用可吸收线间断缝合。对照组手术方法:暴露宫颈后不用做切口,直接在宫颈体上部靠近宫颈内口水平,穿透黏膜,深达宫颈肌层的2/3,分别从4个象限避开膀胱,直肠和向外膨出的羊膜囊进针行荷包缝合,缝扎后以宫颈容纳一指尖为度,针间缝线套塑料圈缓冲张力。查无活动性出血和羊水流出,手术结束。术前后常规剂量应用硫酸镁针抑制宫缩,预防流产,两组药物应用时间和剂量均相同。结果观察组20例中16例孕至37周拆线后自然分娩,3例孕至32周自然发动宫缩,抑制宫缩治疗效差,拆线后早产,一月后随访19例新生儿均成活。1例孕20周自然发动宫缩,抑制宫缩治疗效差,拆线后难免流产。对照组20例中8例孕至37周拆线后自然分娩,4例孕至32周后自然发动宫缩,抑制宫缩药物治疗效差,拆线后早产,一月后随访新生儿均成活,8例孕20周前自然发动宫缩,抑制宫缩药物治疗无效,拆线后难免流产。足月产儿率观察组80%对照组40%,以保至孕28周以上为手术成功依据,手术成功率观察组95%,治疗组60%。两组术后3d观察无宫颈裂伤、膀胱损伤、胎膜早破和流产等并发症出现。结论本研究提示改良的Shirodker手术和MeDonald宫颈环扎手术两种手术对子宫的刺激性小,并发症小,较安全。观察组足月产儿率和手术成功率明显高于对照组,且并发症较对照组无增多,手术效果显著。
Objective To evaluate the effectiveness and safety of the modified Shirodker procedure. Methods Forty-five patients with intrauterine pregnancy who had intrauterine pregnancy for 14-15 weeks were diagnosed as cervical incompetence and cervical cerclage were randomly divided into observation group and control group, with 20 cases in each group. The observation group received modified Shirodker operation , Control group MeDonald cervical cerclage surgery, postoperative pregnancy outcomes and postoperative complications were compared. Observation group surgical methods: take lithotomy bits, conventional disinfection of the exposed cervix, cervical incision in the anterior cervical incision level, the bladder pushed to the level of the cervix within the mouth. The same method incision in the rear of the cervix, the rectum and Douglas nest peritoneum pushed up to the level of the cervix. More than the surgical procedure with the control group, purse suture knot before and after incision with absorbable interrupted suture. The control group surgical methods: do not do incision after exposure to the cervix, directly in the upper part of the cervix close to the level of the cervix, penetrating the mucosa, deep cervical myometrium 2/3, respectively, from the quadrant to avoid the bladder, rectum and outward Bulging amniotic sac into the needle line purse suture, after the suture to accommodate a fingertip for the degree of the cervix, suture needle set plastic ring buffer tension. Check no active bleeding and amniotic fluid outflow, the end of surgery. Preoperative and postoperative conventional dose magnesium sulfate needle inhibition of contractions, prevention of miscarriage, the two groups of drug application time and dosage are the same. Results In the observation group of 16 cases, from 20 cases of pregnancy to 37 weeks of spontaneous delivery, 3 cases of spontaneous uterine contractions during the first trimester of pregnancy and 32 weeks of pregnancy suppressed the efficacy of uterine contractions and premature delivery after suture removal. All the 19 neonates survive. 1 case of pregnancy 20 weeks of natural contractions, inhibition of contraindication treatment ineffective, stitches are inevitable abortion. In the control group, 8 cases were delivered with natural delivery from 8 weeks to 37 weeks after removal of stitches, and 4 cases started contractions spontaneously after 32 weeks of pregnancy. The effect of inhibiting uterine contractions was poor. Premature delivery after suture removal and neonatal follow-up after 1 month were all survival , 8 cases of pregnancy before 20 weeks of natural contractions, inhibition of uterine contractions drug treatment ineffective, stitches inevitable abortion. The full-term infantile rate observation group 80% of the control group 40%, to protect pregnancy more than 28 weeks based on the success of surgery, surgical success rate of 95% in the observation group, 60% of the treatment group. No complications of cervical laceration, bladder injury, premature rupture of membranes and abortion were observed in the two groups after operation. Conclusions This study suggests that both modified Shirodker and MeDonald cervical cerclage surgery are less irritating and have less complications and saferness. Observation group full-term neonatal rate and success rate was significantly higher than the control group, and complications than the control group increased, the effect of surgery was significant.