Cervical length &

Current Opinion in Obstetrics & Gynecology

Prediction of 19, preterm
April 2007 p.191~195

labor
R2
Abstract

Purpose of review: summary in clinical

use of cervical length for prediction of
preterm birth.
Abstract
Aymptomatic women c prior cone biopsy,
mullerian anomalies, multiple D&C.
Asymptomatic women once short cervical
length
prior preterm birth
cervical length < 25 mm.
Preventing preterm birth benefit of USG-
indicated cerclage(progesterone &
indomethacin)
Abstract
Symptomatic preterm labor: knowledge
of cervical length (fetal fibronectin)
beneficial
Time to triage
Reduction of preterm birth
Abstract
Transvaginal ultrasound cervical length
Screening tool for prediction preterm birth
Prevention of preterm birth significantly
improve health outcomes of pregnant pts &
their babies.
Introduction
Preterm birth (PTB) : over 12% of births
in the USA, over 500000/ yr
incidence is increasing .

PTB: main cause of perinatal morbidity

and mortality most important in
obstetrics
Cervical length by
transvaginal ultrasound
Best predictive accuracy: CL < 25 mm.
Different populations (Spontaneous PTB <GA
35 wks)
asymptomatic low-risk or high-risk women with
singleton gestations,
women with twin,triplet pregnancies
symptomatic women with preterm labor or preterm
premature rupture of membranes (PPROM).
pts with cerclage in place.
More relevant studies and recent advances
Cervical length as a
screening
Specific criteria for screening test
Cinically important & prevalent condition.
PTB : main cause of perinatal morbidity &
mortality.
Safe & well accepted.
1. safe & no inoculation of bacteria (ex PPROM)
2. well accepted by pregnant women.
3. Pain and severe discomfort < 2%
Cervical length as a
screening
Recognize disease in asymptomatic phase.

1. Initially, internal os progressively shortens Cx

widens along endocervical canal from internal
towards external os. external os opens.
2. earliest changes at internal os :asymptomatic,
only detected by TVU of Cx.

Well described technique, reliable,

reproducible
Cervical length as a
screening
Have validity
Digital vs TVU examinations of CL every 2 wks
(GA 14 ~GA 30) predict PTBTVU much
stronger

subjective

not accurate for evaluating internal os and nonspecific
(1516% of primipara 1735% of multipara :12 cm
dilated Cx in late 2nd trimester)
Sonographic cervical length :11 mm longer than
manual estimations.
TVU superior to manual exam for evaluation
of Cx & prediction of preterm birth.
Cervical length as a
screening

Intervention prevent outcome.

Cervical length shortens, cerclage
Other interventions : indomethacin,
progesterone, antibiotics in asymptomatic
women & PTL protocol in symptomatic
women
Predictive accuracy of CL &
prevention of preterm birth in
different populations
Low-risk
Mean of 3540 mm (GA 14 ~30 wk ) lower 10th
percentile: 25 mm.
Progressive shortening of Cx after 30 wks
Shorter cervical length higher risk for PTB.
Positive predictive value for CL: 1534 mm 6 ~ 44%
[sensitivity low]
82% short CL at 24 weeks delivered at or after 35
weeks
USG-indicated cerclage not prevent PTB not
recommend cervical length as a routine screening
predictor of PTB in low-risk women.
Table 1
Prior preterm birth
CL : good predictor of PTB in women at high
risk(prior PTB ).
Sensitivity 6080%, positive predictive value:
70% ( CL < 25 mm,GA14~ 18 wks )
High-risk pts c nl CL (GA14~ 18 wks ) : 4%
risk of preterm.
Timing of TVU cervical length screening in
this population is proposed in Fig. 1.
Timing of TVU cervical
length screening prior
preterm birth
Prior preterm birth
We usually stop cervical length
measurements at 28 weeks.
High-risk women of short cervical length
often present with PPROM
USG-indicated cerclage (detection of
short cervical length): 39% in PTB <35
weeks
Other high-risk women
Women with prior cone biopsy , prior multiple
D&Es mullerian anomalies (Table 1).
Uterine anomalies & short cervix : 13-fold in
spontaneous preterm birth( ex unicornuate ut:
highest rate of preterm birth)
Insufficient data to assess efficacy of cerclage
in this population .
Multiple gestations
PTB: one of most significant contributors to
morbidity & mortality in multiple gestations.
Shortened cervical length :
predictive accuracy varies
low sensitivity
high positive predictive value for PTB
Cervical length <2 cm : 100% predictive value
for PTB ( before 28 wks )
Cervical length <2.5 cm (at 24 weeks) strong
predictor of PTB
Multiple gestations
CL > 3.5 cm at 1826 wks : 4% delivered
prior to 35 wks.
Triplet gestations :TVU CL -predictive of PTB
More likley short Cx at 24 wks difficult to
discern
whether short cervix : inherent to women with
multiple gestations
short cervical length later in 2nd trimester in
multiple gestations: <== secondary to rapidly
expanding ut putting extra pressure on lower part
of Ut (not secondary to insufficient cervix)
Multiple gestations
CL < 2.0 cm or > 3.5 cm : prediction of
PTB in twin gestations.
CL: prediction of PTB in multiple
gestations applicability limited
USG-indicated cerclage: recently
215% increase in PTB in women c
asymptomatic short CL & twin
gestations
Post cerclage
Evaluation of CL before & after cerclage
placement : Cx in length following cerclage
term delivery incidence
Similar predictive accuracy for PTB as CL
CL <2.5 cm & CL above cerclage of < 1 cm
best predictors of PTB
Post cerclage
Similar to other populations, shortening of CL benefit
following cerclage no proven intervention
For patients post history-indicated cerclage, if CL
following procedure < 25 mm, placing a re-enforcing
cerclage worse prognosis , should not be done.
Not recommend routine repeated CL measurement
following ultrasound-indicated or physical exam-
indicated cerclages ( no intervention studied to affect
outcome)
Funneling
<25% funneling :not associated risk for PTB
> 25% funneling : risk for PTB
CL : preferred method to screen Cx for risk of
PTB,
Funneling & short cervical length : much
worse predictor of PTB than short cervical
length alone
Funneling in normal length Cx (>=25 mm)
increases risk for PTB (?) unclear
Other interventions-
Indomethacin
Most asymptomatic women c short CL:
painless Ut contractions
Indomethacin : effective at preventing PTB at
48 h, 7 days, less than 37 wks with PTL.
Asymptomatic women c short CL < 25 mm on
TVU at 1624 weeks Indomethacin
31% decrease in PTB before 35 wks
86% decrease in PTB before 24 wks
Other interventions-
Progesterone
Effective in reducing incidence of PTB in
women c prior PTB 1/3.
Using 17 hydroxy-progesterone caproate in
women with short CL on TVU. possible
decrease in PTB (Unpublished data ,Nicolaides &
colleagues, 2006, International Society of Ultrasound
in Obstetrics and Gynecology (ISUOG))
Insufficient data to assess efficacy of this
intervention
Antibiotics
Antibiotics for preventing PTB not
very successful in prolongation of
pregnance (except PPROM)
Most recently, antibiotics for
asymptomatic women c short CL : not
efficacious in improving outcomes
Preterm labor
Symptomatic women with PTL at high risk for
PTB, but most of them deliver at term even
without interventions.
Compared with women in whom cervical
length and fetal fibronectin (FFN) results
similar women with CL and FFN available for
management decisions were triaged about
half an hour earlier& less incidence of PTB
Conclusion
Cervical length by TVU best available
technique for predicting PTB.
Safe, well accepted, reliable, valid in all
populations studied.
Cervical length of less than 25 mm ( 16 ~ 24
weeks) : most reliable threshold for increased
risk of PTB.
Shorter cervical length higher risk of PTB.
Conclusion
Earlier in GA shortening occurs higher risk.
Screening frequency: severity of obstetrical
Hx, especially in high-risk populations.
Prevention strategies,once short cervical
length is detected benefit from ultrasound-
indicated cerclage.
Prior preterm birth or 2nd trimester loss
TVU cervical length < 25 mm at 1623 wks
with singleton gestation
Conclusion
Other interventions based on short cervical
length indomethacin & progesterone.
Recent trial ( use of cervical length & FFN)
threatened PTL : shorter time to triage &
decreased incidence of PTB.
Cervical length significant role in prediction of
PTB Prevention of this common & severe
complication
Screening tool : potential to significantly
improve health outcomes of pregnant pts &
babies