SHORT CERVIX – WHAT NOW?
Abstract
Background: It is possible to predict preterm delivery (PD) before 34 weeks by ultrasound measurement of uterine cervical length (CL). This is the reason why this screening method is more frequently used in clinical practice.
Methods: I extracted from PubMed database Crane’s sistematic review and articles about association of CL with PD and instructions what is necessary to take into consideration and what to do in case of a short cervix.
Results: Majority of studies suggested CL of 25 mm as a cut-off point for selecting pregnancy as high risk for PD. Minority of studies also used 15 mm as a cut-off point. This inconsistency in selecting an unique cut-off point, as some authors showed, is a result of ignoring gestational age when measurement of CL is made. CL is usually measured until 24 weeks of pregnancy and value of US measurement of CL made later in pregnancy or role of follow-up measure- ments are still unclear.
In cases with threatened preterm labour where CL is measured there was 66 % reduction of unnecessary tocolysis. US measurement of CL is of a little value if there is a progressive dilatation of cervix (Bishop score > 6). Shirodkar cerclage in women with short cervix does not reduce the risk for PD. Vaginal progesteron causes a 50 % decrease of incidence of PD in women with short cervix (CL < 15 mm). We do not know which form of vaginal progesteron is most effective. Progesteron is uneffective in women with PD in previous pregnancy and CL > 25 mm.
Conclusions: US measurement of CL becomes reliable criteria for detecting pregnancies with increased risk for PD before 34 weeks of pregnancy. It enables individual risk calculation for PD with consideration of other risk factors.
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References
Marlow N, Wolke D, Bracewell MA, Samara M. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med 2005; 352: 9–19.
NicolaidesKH.Somethoughtsonthetruevalueofultrasound. Ultrasound Obstet Gynecol 2007; 30: 671–4.
GoldenbergRL,CulhaneJF,IamsJD,RomeroR.Epidemiology and causes of preterm birth. Lancet 2008; 371: 75–84.
Honest H, Bachmann LM, Sundaram R, Gupta JK, Kleijnen J, Khan KS. The accuracy of risk scores in predicting preterm birth--a systematic review. J Obstet Gynaecol 2004; 24: 343–59.
Leitich H. Secondary predictors of preterm labour. BJOG 2005; 112 Suppl 1: 48–50.
BerghellaV.Noveldevelopmentsoncervicallengthscreening and progesterone for preventing preterm birth. BJOG 2009; 116: 182–7.
Owen J, Iams JD. What we have learned about cervical ultra- sound. Semin Perinatol 2003; 27: 194–203.
DoyleNM,MongaM.Roleofultrasoundinscreeningpatientsat risk for preterm delivery. Obstet Gynecol Clin North Am 2004; 31: 125–39.
LeitichH,BrunbauerM,KaiderA,EgarterC,HussleinP.Cervi- cal length and dilatation of the internal cervical os detected by vaginal ultrasonography as markers for preterm delivery: A systematic review. Am J Obstet Gynecol 1999; 181: 1465–72.
VendittelliF,VolumenieJ.Transvaginalultrasonographyexami- nation of the uterine cervix in hospitalised women undergoing preterm labour. Eur J Obstet Gynecol Reprod Biol 2000; 90: 3–11.
Honest H, Bachmann LM, Coomarasamy A, Gupta JK, Kleijnen J, Khan KS. Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review. Ultrasound Obstet Gynecol 2003; 22: 305–22.
Romero R. Prevention of spontaneous preterm birth: the role of sonographic cervical length in identifying patients who may benefit from progesterone treatment. Ultrasound Obstet Gynecol 2007; 30: 675–86.
SalomonLJ,Diaz-GarciaC,BernardJP,VilleY.Referencerange for cervical length throughout pregnancy: non-parametric LMS- based model applied to a large sample. Ultrasound Obstet Gynecol 2009; 33: 459–64.
Palacio M, Sanin-Blair J, Sanchez M, Crispi F, Gomez O, Carreras E et al . The use of a variable cut-off value of cervical length in women admitted for preterm labor before and after 32 weeks. Ultrasound Obstet Gynecol 2007; 29: 421–6.
Hoesli IM, Strutas D, Tercanli S, Holzgreve W. Charts for cervical length in singleton pregnancy. Int J Gynaecol Obstet 2003; 82: 161–5.
Bergelin I, Valentin L. Patterns of normal change in cervical length and width during pregnancy in nulliparous women: a prospective, longitudinal ultrasound study. Ultrasound Obstet Gynecol 2001; 18: 217–22.
Crane JM, Hutchens D. Transvaginal sonographic measurement of cervical length to predict preterm birth in asymptomatic women at increased risk: a systematic review. Ultrasound Obstet Gynecol 2008; 31: 579–87.
CraneJM,DelaneyT,HutchensD.Transvaginalultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia. Obstet Gynecol 2006; 107: 37–44.
Durnwald CP, Walker H, Lundy JC, Iams JD. Rates of recurrent preterm birth by obstetrical history and cervical length. Am J Obstet Gynecol 2005; 193: 1170–4.
Airoldi J, Berghella V, Sehdev H, Ludmir J. Transvaginal ultra- sonography of the cervix to predict preterm birth in women with uterine anomalies. Obstet Gynecol 2005; 106: 553–6.
de Carvalho MH, Bittar RE, Brizot ML, Bicudo C, Zugaib M. Prediction of preterm delivery in the second trimester. Obstet Gynecol 2005; 105: 532–6.
BerghellaV,PereiraL,GariepyA,SimonazziG.Priorconebiopsy: prediction of preterm birth by cervical ultrasound. Am J Obstet Gynecol 2004; 191: 1393–7.
Berghella V, Talucci M, Desai A. Does transvaginal sonographic measurement of cervical length before 14 weeks predict preterm delivery in high-risk pregnancies? Ultrasound Obstet Gynecol 2003; 21: 140–4.
To MS, Alfirevic Z, Heath VC, Cicero S, Cacho AM, Williamson PR et al . Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial. Lancet 2004; 363: 1849–53.
Guzman ER, Walters C, Ananth CV, O'Reilly-Green C, Benito CW, Palermo A et al. A comparison of sonographic cervical parameters in predicting spontaneous preterm birth in high- risk singleton gestations. Ultrasound Obstet Gynecol 2001; 18: 204–10.
Owen J, Yost N, Berghella V, Thom E, Swain M, Dildy GA, III et al . Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth. JAMA 2001; 286: 1340–8.
Owen J, Yost N, Berghella V, MacPherson C, Swain M, Dildy GA, III et al . Can shortened midtrimester cervical length predict very early spontaneous preterm birth? Am J Obstet Gynecol 2004; 191: 298–303.
Andrews WW, Copper R, Hauth JC, Goldenberg RL, Neely C, Dubard M. Second-trimester cervical ultrasound: associations with increased risk for recurrent early spontaneous delivery. Obstet Gynecol 2000; 95: 222–6.
Cook CM, Ellwood DA. The cervix as a predictor of preterm delivery in 'at-risk' women. Ultrasound Obstet Gynecol 2000; 15: 109–13.
Berghella V, Daly SF, Tolosa JE, DiVito MM, Chalmers R, Garg N et al . Prediction of preterm delivery with transvaginal ultra- sonography of the cervix in patients with high-risk pregnancies: does cerclage prevent prematurity? Am J Obstet Gynecol 1999; 18: 809–15.
Watson WJ, Stevens D, Welter S, Day D. Observations on the sonographic measurement of cervical length and the risk of premature birth. J Matern Fetal Med 1999; 8: 179.
Alfirevic Z, Allen-Coward H, Molina F, Vinuesa CP, Nicolaides K. Targeted therapy for threatened preterm labor based on sonographic measurement of the cervical length: a randomized controlled trial. Ultrasound Obstet Gynecol 2007; 29: 47–50.
Kagan KO, To M, Tsoi E, Nicolaides KH. Preterm birth: the value of sonographic measurement of cervical length. BJOG 2006; 113 Suppl 3: 52–6.
Tsoi E, Fuchs IB, Rane S, Geerts L, Nicolaides KH. Sonographic measurement of cervical length in threatened preterm labor in singleton pregnancies with intact membranes. Ultrasound Obstet Gynecol 2005; 25: 353–6.
Tsoi E, Geerts L, Jeffery B, Odendaal HJ, Nicolaides KH. Sono- graphic cervical length in threatened preterm labor in a South Af- rican population. Ultrasound Obstet Gynecol 2004; 24: 644–6.
Fuchs I, Tsoi E, Henrich W, Dudenhausen JW, Nicolaides KH. Sonographic measurement of cervical length in twin pregnan- cies in threatened preterm labor. Ultrasound Obstet Gynecol 2004;23: 42–5.
Tsoi E, Akmal S, Rane S, Otigbah C, Nicolaides KH. Ultrasound assessment of cervical length in threatened preterm labor. Ul- trasound Obstet Gynecol 2003; 21: 552–5.
Volumenie JL, Luton D, De Spirlet M, Sibony O, Blot P, Oury JF. Ultrasonographic cervical length measurement is not a bet- ter predictor of preterm delivery than digital examination in a population of patients with idiopathic preterm labor. Eur J Obstet Gynecol Reprod Biol 2004; 117: 33–7.
Althuisius SM. The short and funneling cervix: when to use cerclage? Curr Opin Obstet Gynecol 2005; 17: 574–8.
Pieber D, Allport VC, Hills F, Johnson M, Bennett PR. Interactions between progesterone receptor isoforms in myometrial cells in human labour. Mol Hum Reprod 2001; 7: 875–9.
Macdonald RR. Does treatment with progesterone prevent miscarriage? Br J Obstet Gynaecol 1989; 96: 257–60.
Greene MF. Progesterone and preterm delivery-deja vu all over again. N Engl J Med 2003; 348: 2453–5.
Iams JD. Supplemental progesterone to prevent preterm birth. Am J Obstet Gynecol 2003; 188: 303.
Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Proges- terone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007; 357: 462–9.
O‘Brien JM, Adair CD, Lewis DF, Hall DR, DeFranco EA, Fusey S et al . Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2007; 30: 687–96.
da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M. Prophylactic administration of progesterone by vaginal suppository to re- duce the incidence of spontaneous preterm birth in women at increased risk: a randomized placebo-controlled double-blind study. Am J Obstet Gynecol 2003; 188: 419–24.
Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Thom EA, Spong CY et al . A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. N Engl J Med 2007; 357: 454–61.
Klebanoff MA. Subgroup analysis in obstetrics clinical trials. Am J Obstet Gynecol 2007; 197: 119–22.
Kavšek G. Transvaginalni ultrazvočni pregled materničnega vratu v nosečnosti. Med razgl 2005; 44 Suppl 2: 93–102.
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