Endocervical Canal Length Research Articles

Recurrence in Cervical High-Grade Squamous Intraepithelial Lesion: The Role of the Excised Endocervical Canal Length-Analysis of 2,427 Patients.

This study aimed to evaluate the influence of the excised canal length on relapse rates of cervical high-grade squamous intraepithelial lesion (HSIL) treated by loop electrosurgical excision procedure and to find a cut-off point, above which lower recurrence rates could be observed, with low probability of compromising future obstetric outcome, and the relationship with other individual factors related to HSIL recurrence. This was a retrospective cohort study of 2,427 women diagnosed with cervical intraepithelial neoplasia CIN2+ who underwent cervical conization using the high-frequency loop electrosurgical excision procedure surgery technique, to analyze the role of endocervical canal length associated with individual factors in the recurrent disease after CIN2+ treatment and determine a cut-off point for the excised canal length needed to decrease the risk of disease relapse. In 2,427 cases, the relapse rate of HSIL treated was 12%. Compromised margins of conization, HIV+, and endocervical canal length were related directly to relapses ( p < .001). The cut-off point, by receiver operating characteristic curve, to calculate the endocervical canal length related to relapses was 1.25 cm of canal excised. Canal length of less than 1.25 cm increased the recurrence rate 2.5 times. Compromised margins and HIV+ increased recurrence rates by more than 5 times. Cervical HSIL recurrence was directly related to the endocervical canal length: excised canal length of 1.25 cm or more decreases recurrence rate; HIV and compromised margins increase the chance of recurrence by more than 5 times.

Imaging to assist fertility-sparing surgery.

Cytological screening and human papilloma virus testing has led to diagnosis of cervical cancer in young women at an earlier stage. Defining the full extent of the disease within the cervix with imaging aids the decision on feasibility of fertility-sparing surgical options, such as extended cone biopsy or trachelectomy. High spatial resolution images with maximal contrast between tumour and surrounding background are achieved with T2-weighted and diffusion-weighted (DW) magnetic resonance imaging (MRI) obtained using an endovaginal receiver coil. Tumour size and volume demonstrated in this way correlates between observers and with histology and differences between MRI and histology estimates of normal endocervical canal length are not significant. For planning fertility-sparing surgery, this imaging technique facilitates the best oncological outcome while minimising subsequent obstetric risks. Parametrial invasion may be assessed on large field of view T2-weighted MRI. The fat content of the parametrium limits the utility of DW imaging in this context, because fat typically shows diffusion restriction. The use of contrast-enhanced MRI for assessing the parametrium does not provide additional benefits to the T2-weighted images and the need for an extrinsic contrast agent merely adds additional complexity and cost. For nodal assessment, 18fluorodeoxyglucose positron emission tomography-computerised tomography (18FDG PET-CT) remains the gold standard.

The Value of Late Mid-Trimester Ultrasound Cervical Assessment after Cerclage for the Prediction of Preterm Birth

Background: Spontaneous preterm birth constitutes a significant obstetric dilemma as prematurity is a major risk factor of neonatal death or a lifelong morbidity. Despite extensive efforts to reduce preterm birth, the means to identify and prevent it remains limited. Sonographic surveillance of CL can identify the increased risk of spontaneous preterm birth. Objective: To determine the predictive value of ultrasonographic assessment of the cervix after cerclage insertion for the outcome of preterm birth before 34 weeks of gestation. Patients and Methods: A prospective study included fifty women with singleton pregnancies were followed-up with monthly transvaginal ultrasonographic examinations before and after cerclage insertion. Ultrasonographic parameters of the cervix included the closed endocervical canal length and funneling depth measured from the internal cervical os. Results: The change in cervical length was predictive; as with stable cervical length an association with a later gestational age at delivery was evident. Patients with cerclage who delivered after 34 weeks had a slower rate of cervical shortening compared to those who delivered prior to that date (median = 4mm versus 7mm per 4 weeks). The overall cervical length at 28 weeks was statistically different between patients who delivered before 34 weeks and those who delivered later (24.00±2.92 versus 33.19±5.5 p<0.001). Conclusions: Transvaginal ultrasound for cervical assessment can be a helpful tool in the prediction of preterm birth after cerclage insertion. A late second-trimester cervical transvaginal ultrasound scan can guide the addition of interventions such, progesterone and antenatal corticosteroids for fetal lung maturation.

Preoperative imaging in patients undergoing trachelectomy for cervical cancer: Validation of a combined T2- and diffusion-weighted endovaginal MRI technique at 3.0 T

AimThe aim of this study is to validate high-resolution endovaginal T2- and diffusion-weighted MRI measurements (tumour size, volume and length of uninvolved cervical canal) against histology in patients undergoing trachelectomy. Patients/interventions55 consecutive patients 25–44years with cervical cancer being considered for trachelectomy were prospectively assessed with endovaginal T2-W and diffusion-weighted MRI. Two independent observers blinded to histology recorded maximum tumour dimension, volume and distance from the superior aspect of the tumour to the internal os. Following trachelectomy, pathologist-outlined tumour sections were photographed with a set scale and similar measurements were recorded. ResultsFifteen of 45 patients subsequently treated with fertility-sparing surgery had residual tumour (median histological volume: 0.28cm3, IQR=0.14–1.06cm3). Sensitivity, specificity, positive and negative predictive values for detecting tumour: Observer1: 86.7%, 80.0%, 68.4%, and 92.3%, respectively; Observer2: 86.7%, 90.0%, 81.0%, and 93.1%, respectively. Size and volume correlated between observers (r=0.96, 0.84, respectively, p<0.0001). Size correlated between each observer and histology (observer 1 r=0.91, p<0.0001; observer 2 r=0.93, p<0.0001), volume did not (observer 1: r=0.08, p=0.6; observer 2: r=0.21, p=0.16); however, differences between observer measurements and histology were not significant (size p=0.09, volume p=0.15). Differences between MRI and histology estimates of endocervical canal length were not significant (p=0.1 both observers). ConclusionIn subcentimetre cervical cancers, endovaginal MRI correlates with pathology and is invaluable in assessing patients for fertility-sparing surgery.

Prediction of Spontaneous Onset of Labor at Term: The Role of Cervical Length Measurement and Funneling of Internal Cervical Os Detected by Transvaginal Ultrasonography

The objective of this study was to examine the values of the cervical length measurement and detection of internal cervical os funneling by transvaginal ultrasonography in the prediction of spontaneous labor within a 7-day period at term. Ninety-three pregnant women were enrolled into this study. All patients were evaluated by transvaginal ultrasonography first at the 37th completed week of gestation and weekly thereafter. Endocervical canal length was measured and the presence of funneling was recorded. The end points were the percentage of patients with a spontaneous onset of labor in the week after these data were recorded. The optimal cutoff values for predicting the onset of spontaneous labor within 7 days were 29.5 mm for cervical length at 37 weeks, 27.5 mm at 38 weeks, 25.5 mm at 39 weeks, and 24.5 mm at 40 weeks of gestation. There was also statistically significant agreement between the presence of the funneling and spontaneous labor within 7 days. Measurement of cervical length and detection of funneling at the internal cervical os by transvaginal ultrasonography might help us to predict the spontaneous onset of labor in a 7-day period, and help clinicians to decide about the time of labor induction in certain complicated pregnancies.

The prediction of spontaneous preterm birth in women with threatened preterm labor using transvaginal ultrasound of the cervix

Purpose: This study was to determine if cervical parameters, as assessed by transvaginal ultrasound, were predictive of spontaneous preterm birth in women following an episode of threatened preterm labor (TPL).Methods: Women with a singleton pregnancy (20–34 weeks gestation) and intact membranes were enrolled following admission for TPL. The transvaginal ultrasound assessment of the cervix was performed when uterine activity had ceased. Only the ultrasound relating to the episode of suspected preterm labor is reported.Results: Sixty women had a transvaginal scan performed at a gestation of 27.7 ± 3.7 weeks (mean ± SD) (range 20.1–33.7 weeks). Cervical parameters were significantly different in women who delivered preterm (shorter closed endocervical canal length –P &lt; 0.0001; increased internal os dilatation –P &lt; 0.0001) to the women who delivered at term. Twenty‐five women had an abnormal cervix (closed endocervical canal length &lt;30 mm + internal os dilatation &gt;5 mm). Of these, 16 (64%) delivered preterm (&lt;37 weeks). In contrast, only one woman with a normal cervix delivered preterm (P &lt; 0.0001; RR 22.4, 95% CI 3.17–158.1). Five women (20%) delivered within 1 day of their abnormal cervical ultrasound, seven (28%) in &lt;7 days, and 10 (40%) in &lt;14 days whereas no woman with a normal cervical ultrasound delivered within 14 days (sensitivity 100%; negative predictive value 100%). In a linear regression model with gestational age at delivery as the dependent variable, endocervical canal length had an R2 of 59.3% (P &lt; 0.0001) which was not improved by the addition of any of the other parameter variables.Conclusions: Transvaginal ultrasound of the cervix can identify those women with an abnormal cervix following an episode of TPL who are at increased risk of preterm birth. It also identifies the women with normal cervices and therefore at low‐risk of preterm birth which potentially could reduce unnecessary interventions.

The Cervix as a Predictor of Preterm Delivery in ‘At-Risk’ Women

Objective To examine the relationship between ultrasound-determined cervical status and pregnancy outcome in women ‘at-risk’ of spontaneous preterm delivery. Design A prospective cohort study of 120 pregnant women considered to be ‘at-risk’ of spontaneous preterm delivery by their clinician. Transvaginal ultrasound of the cervix was used to assess overall cervical length, closed endocervical canal length, diameter and internal os dilatation in the second trimester. The main outcome measure was occurrence of spontaneous preterm birth (< 34 and < 37 weeks of gestation). Results The overall preterm delivery rate (< 37 weeks gestation) in these women was 35% (n = 42) with 20% (n = 24) delivering < 34 weeks gestation. Of the 71 women with a normal cervix, 8 (11%) delivered < 34 weeks, whereas of the 49 women with an abnormal cervix, 16 (33%) delivered < 34 weeks (RR 2.90; 95% CI 1.35–6.24). Using linear regression, closed endocervical canal length of < 21 mm before 20 weeks is associated with delivery < 34 weeks in 95% of women, and with delivery < 37 weeks in 95% of women if the canal length is < 33 mm. Logistic regression showed closed endocervical canal length to be the only significant factor in those women who delivered < 34 weeks after controlling for possible confounders. Conclusions A strong relationship is demonstrated between cervical status and pregnancy outcome, particularly the cervical findings before 20 and 24 weeks of gestation. The length of the closed portion of the endocervical canal is the best predictor. A beneficial effect of this approach to ‘at-risk’ women is the reduction in unnecessary interventions in those with normal cervical findings.

Is there a relationship between uterine activity and the length of the cervix in the second trimester?

The purpose of this study was to determine if a relationship could be detected between uterine activity and cervical change in the second trimester. Ten women with evidence of cervical change and 10 women with no cervical change (controls) were studied between 20 and 28 weeks gestation. Uterine activity was recorded using home uterine activity monitoring units. Cervical assessment was performed using transvaginal ultrasound. There was no statistically significant difference in the contractions per hour in the cervical change group (1.26 +/- 0.38; mean +/- SEM) compared to the controls (1.13 +/- 0.48) (p 0.48; Mann-Whitney U test). There were significant differences in closed endocervical length (p < 0.001) and internal os dilatation (p 0.004), the cervical change group demonstrating a shorter closed endocervical length and greater internal os dilatation. This preliminary study shows no evidence of a relationship between uterine activity and endocervical canal length in the second trimester.

The cervix as a predictor of preterm delivery in 'at-risk' women.

To examine the relationship between ultrasound-determined cervical status and pregnancy outcome in women 'at-risk' of spontaneous preterm delivery. A prospective cohort study of 120 pregnant women considered to be 'at-risk' of spontaneous preterm delivery by their clinician. Transvaginal ultrasound of the cervix was used to assess overall cervical length, closed endocervical canal length, diameter and internal os dilatation in the second trimester. The main outcome measure was occurrence of spontaneous preterm birth (< 34 and < 37 weeks of gestation). The overall preterm delivery rate (< 37 weeks gestation) in these women was 35% (n = 42) with 20% (n = 24) delivering < 34 weeks gestation. Of the 71 women with a normal cervix, 8 (11%) delivered < 34 weeks, whereas of the 49 women with an abnormal cervix, 16 (33%) delivered < 34 weeks (RR 2.90; 95% CI 1.35-6.24). Using linear regression, closed endocervical canal length of < 21 mm before 20 weeks is associated with delivery < 34 weeks in 95% of women, and with delivery < 37 weeks in 95% of women if the canal length is < 33 mm. Logistic regression showed closed endocervical canal length to be the only significant factor in those women who delivered < 34 weeks after controlling for possible confounders. A strong relationship is demonstrated between cervical status and pregnancy outcome, particularly the cervical findings before 20 and 24 weeks of gestation. The length of the closed portion of the endocervical canal is the best predictor. A beneficial effect of this approach to 'at-risk' women is the reduction in unnecessary interventions in those with normal cervical findings.

Pregnancy Outcomes in Women Treated With Elective Versus Ultrasound-Indicated Cervical Cerclage

Objective To compare pregnancy outcomes in women at risk for pregnancy loss treated with elective versus ultrasound-indicated placement of cerclage. Methods A retrospective cohort study was performed on two groups of patients with singleton gestations. The first group consisted of women at risk for pregnancy loss who were treated with an elective cerclage, while the second group was managed conservatively and followed with serial transvaginal cervical sonography and transfundal pressure. An emergency cerclage was placed in women in the second group when the endocervical canal length shortened to < 20 mm, either spontaneously or in response to transfundal pressure. The two groups were compared with respect to maternal demographics, obstetric and gynecological history, and gestational age, both at time of cerclage placement and delivery. Results A total of 138 patients were identified. Eighty-one patients were treated with an elective cerclage and 57 with an ultrasound-indicated cerclage. Patients treated with elective cerclages were older (32 versus 27 years, p = 0.0003), more commonly white (56.8% versus 38.6%, p = 0.0380), less commonly nulliparous (23.5% versus 43.9%, p = 0.0063), and more often private patients (92.6% versus 28.1%, p < 0.0001). A history of previous treatment with cerclage (45.7% versus 10.5%, odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1–0.4) and one prior midtrimester loss (53.1% versus 33.3%, OR 0.4, 95% CI 0.2–0.9) were also more common in the elective versus ultrasound-indicated cerclage group. However, there was no difference in the rates of previous preterm delivery, two midtrimester losses, two terminations of pregnancy, in utero diethylstilbestrol exposure, uterine anomalies, history of cone biopsy or parity. As expected, gestational age at placement of cerclage was significantly earlier in the elective group (13.0 versus 20.0 weeks, p < 0.0001). The median (range) gestational age at delivery (37 (15–41) versus 37 (17–41) weeks, p = 0.90), the number of early (< 25 weeks) losses (9.9% versus 8.8%, OR 1.6, 95% CI 0.3–7.9), and preterm deliveries (< 37 weeks) (35.8% versus 36.8%, OR 1.1, 95% CI 0.4–3.2) were similar in the elective and ultrasound-indicated cerclage patients, respectively. Conclusion In patients at risk for pregnancy loss, placement of cervical cerclages in response to ultrasono-graphically detected shortening of the endocervical canal length is a medically acceptable alternative to the use of elective cerclage. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

Relationship between endocervical canal length between 15–24 weeks gestation and obstetric history

The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to <2 cm or a single endocervical canal length measurement <2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15–20 weeks and 21–24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pregnancies. Chi-square test was used to determine the relationship between the development of an ultrasound diagnosis of cervical incompetence and the earliest gestational age at delivery of prior pregnancies. A total of 155 pregnancies were studied. The number of women according to the obstetric history categories were: 57 had delivered <24 weeks, 12 between 24 and 26 weeks, 16 between 27 and 32 weeks, 16 between 33 and 36 weeks, and 54 delivered ≥37 weeks. There was a significant correlation between the endocervical canal length measurements between 15–20 (P < 0.0001) weeks and 21–24 weeks (P < 0.0001) in the studied pregnancy and the earliest gestational age at delivery of prior pregnancies. A significant relationship between the ultrasound diagnosis of cervical incompetence and the obstetric history category (P = 0.0026) was observed. There were 36 cases of ultrasound diagnosed cervical incompetence with 91.7% (33/36) occurring in women who had a prior <27 weeks' gestation delivery. These data provide further evidence that cervical incompetence is a relative condition and not an “all or none” phenomenon. In addition, women with a prior delivery <30 weeks gestation should be followed with second trimester serial cervical sonography to rule out cervical incompetence. J. Matern.-Fetal Med. 7:269–272, 1998. © 1998 Wiley-Liss, Inc.

Relationship between endocervical canal length between 15-24 weeks gestation and obstetric history.

The object was to determine whether there is a correlation between the obstetric history and the ultrasonographically determined endocervical canal length between 15 and 24 weeks gestation. A retrospective cohort study was performed in singleton pregnancies of multigravidas with normal and abnormal obstetric histories. They underwent sonographic evaluation for the determination of the endocervical canal length between 15 and 24 weeks gestation. The shortest endocervical canal length measurements between 15 and 20 weeks and also between 21 and 24 weeks of gestation were recorded. An ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to <2 cm or a single endocervical canal length measurement <2 cm. A multivariable general linear regression model was used to correlate the relationship between endocervical canal lengths at 15-20 weeks and 21-24 weeks gestation in the current pregnancy with the earliest gestational age at delivery of prior pregnancies. Chi-square test was used to determine the relationship between the development of an ultrasound diagnosis of cervical incompetence and the earliest gestational age at delivery of prior pregnancies. A total of 155 pregnancies were studied. The number of women according to the obstetric history categories were: 57 had delivered <24 weeks, 12 between 24 and 26 weeks, 16 between 27 and 32 weeks, 16 between 33 and 36 weeks, and 54 delivered > or =37 weeks. There was a significant correlation between the endocervical canal length measurements between 15-20 (P < 0.0001) weeks and 21-24 weeks (P < 0.0001) in the studied pregnancy and the earliest gestational age at delivery of prior pregnancies. A significant relationship between the ultrasound diagnosis of cervical incompetence and the obstetric history category (P = 0.0026) was observed. There were 36 cases of ultrasound diagnosed cervical incompetence with 91.7% (33/36) occurring in women who had a prior <27 weeks' gestation delivery. These data provide further evidence that cervical incompetence is a relative condition and not an "all or none" phenomenon. In addition, women with a prior delivery <30 weeks gestation should be followed with second trimester serial cervical sonography to rule out cervical incompetence.

Longitudinal Assessment of Endocervical Canal Length Between 15 and 24 Weeks’ Gestation in Women at Risk for Pregnancy Loss or Preterm Birth

Objective: To determine the weekly cervical shortening rates of the endocervical canal between 15 and 24 weeks’ gestation in women at risk for pregnancy loss or spontaneous preterm birth. Methods: We performed a retrospective cohort study of transvaginal sonographic measurements of the endocervical canal length done at least twice between 15 and 24 weeks’ gestation in women at risk for pregnancy loss and spontaneous preterm birth. The ultrasound diagnosis of cervical incompetence was defined as progressive shortening of the endocervical canal length to 2 cm or less either spontaneously or after application of transfundal pressure. Multivariable linear regression models were developed to determine the weekly crude rate of endocervical canal length shortening rates in cases of competent cervices and incompetent cervices, with incompetent cervices further stratified as those diagnosed at 15–19 weeks’ and 20–24 weeks’ gestation. Comparisons of the models for weekly rate of endocervical canal length shortening were performed. Results: The endocervical canal lengths were measured in 61 women (180 measurements) who did not develop ultrasound evidence of cervical incompetence and 28 women (103 measurements) who had ultrasound evidence of cervical incompetence. Between 15 and 24 weeks’ gestation, competent cervices had a nonsignificant rate of endocervical canal length shortening (−0.03 cm/week). During this period in gestation, incompetent cervices had significantly greater endocervical canal length shortening (−0.41 cm/week, P < .001). The rate of endocervical canal length shortening of incompetent cervices diagnosed between 15 and 19 weeks’ gestation was −0.52 cm/week ( P < .001). The rate of endocervical canal length shortening in incompetent cervices diagnosed between 20 and 24 weeks’ gestation was significant and varied from −0.49 cm/week to −0.80 cm/week at 20 and 24 weeks’ gestation, respectively ( P < .001). The models describing the rate of cervical shortening in the two groups of incompetent cervices were significantly different ( P < .001). The sonographic detection of endocervical canal length shortening in the 28 cases of cervical incompetence was identified at a median (range) gestational age of 20 (16–24) weeks. Conclusion: Weekly rates of endocervical canal length shortening were established, which may be useful for detecting and managing cervical incompetence in high-risk women examined with cervical sonography.

Longitudinal Assessment of Endocervical Canal Length Between 15 and 24 Weeksʼ Gestation in Women at Risk for Pregnancy Loss or Preterm Birth

Longitudinal Assessment of Endocervical Canal Length Between 15 and 24 Weeksʼ Gestation in Women at Risk for Pregnancy Loss or Preterm Birth

Relationship between endocervical canal length between 15–24 weeks gestation and obstetric history

Relationship between endocervical canal length between 15–24 weeks gestation and obstetric history

A comparison of ultrasonographically detected cervical changes in response to transfundal pressure, coughing, and standing in predicting cervical incompetence

Objective Our purpose was to compare various noninvasive stress techniques for their ability to elicit ultrasonographic cervical changes and to determine their efficacy in detecting ultrasonographic cervical incompetence. Study design Eighty-nine patients at risk for pregnancy loss and preterm birth underwent ultrasonographic evaluation of the cervix at least twice between 15 and 24 weeks of gestation. With use of a transvaginal probe, the funnel width, funnel length, and endocervical canal length were measured in millimeters with the patient in the supine position. These measurements were repeated after three stress tests: transfundal pressure, coughing, and standing. The difference between the baseline measurements and those obtained after the stress tests were determined. A positive response to stress was defined as any decrease in endocervical canal length accompanied by an increase in funnel width and length. Improvement was defined by any increase in endocervical canal length accompanied by a decrease in funnel width and length. Cervical incompetence was defined as the presence of progressive cervical changes on ultrasonographic examinations with final endocervical canal length measurements below 26 mm. Results are reported as median (range). Results: The number of positive cervical responses to transfundal pressure (19%, 17/89) was significantly greater than to coughing (3.3%, 3/89) and standing (9.0%, 8/89). The status of the cervix improved with standing in three cases, whereas this was not seen with transfundal pressure or coughing. There was no case where there was a positive response to standing or coughing and not to transfundal pressure. When the changes in funnel width and length and endocervical canal length as a result of transfundal pressure and standing in the 17 cases that responded to transfundal pressure, transfundal pressure resulted in a significantly greater increase in funnel width and length and a decrease in endocervical canal length. The efficacy of transfundal pressure in detecting the cervix that had subsequent progressive changes on ultrasonography was as follows: sensitivity 83.3%, specificity 97.2%, and positive and negative predictive values 88.2% and 95.8%, respectively. The efficacy of coughing was sensitivity 16.7%, specificity 100%, and positive and negative predictive values 100% and 85.5%, respectively. The efficacy of standing was sensitivity 33.3%, specificity 97.2%, and positive and negative predictive values 75% and 85.2%, respectively. Similar results were obtained when the analysis was confined to 37 patients who had a prior history of a midtrimester miscarriage. Conclusion: Transfundal pressure was the most effective technique in eliciting cervical changes during the active assessment of the cervix during pregnancy and the most sensitive in detecting the cervix that had progressive second-trimester cervical shortening during pregnancy, compared with coughing or standing position.

The role of transvaginal sonography in predicting recurrent preterm labour in patients with intact membranes

Our purpose was to determine whether funnelling of the cervical internal os, length of the endocervical canal, cervical index, funnel length and funnel width determined by transvaginal sonography are predictive of recurrent preterm labour. Of 112 women, 65 admitted to the hospital for preterm labour with intact membranes had transvaginal sonographic evaluation of the cervix before digital cervical examination and institution of tocolysis. The following measurements were obtained: (1) presence of funnelling, (2) endocervical canal length, (3) cervical index, (4) funnel length and (5) funnel width. Logistic regression analysis was performed to determine the variables that made a significant contribution to the prediction of recurrent preterm labour. A total of 65 eligible women completed the study. Recurrent preterm labour was significantly associated with the presence of funnelling (85.2% vs. 23.3%) and short endocervical canal length, large cervical index and long funnel length as noted on transvaginal cervical sonography. The presence of funnelling, shorter endocervical canal length, larger cervical index and longer funnel length were suggestive of true preterm labour and its recurrence. Transvaginal sonographic examination of the uterine cervix is a useful procedure to predict recurrent preterm labour with intact membranes.

The natural history of a positive response to transfundal pressure in women at risk for cervical incompetence

OBJECTIVE: Our purpose was to observe the evolution of the endocervical canal length in women at risk for cervical incompetence after a positive response to transfundal pressure. STUDY DESIGN: Ten women at risk for cervical incompetence had a midtrimester cervical evaluation with transvaginal ultrasonography and transfundal pressure. With a transvaginal probe, the endocervical canal length was first measured. Transfundal pressure was then applied and the endocervical canal length was remeasured. All patients had a positive response to transfundal pressure as defined by a decrease in endocervical canal length after application of transfundal pressure. At the initial evaluation the digital examination of the cervix had revealed a closed and long cervix in all 10 cases. In 9 of the 10 patients repeat examinations were performed until the endocervical canal length progressively shortened to <10 mm or the digital examination revealed a dilated cervix. The endocervical canal lengths after application of transfundal pressure from the first and last examination were compared. One patient was lost to follow-up, but the obstetric outcome was available. RESULTS: The median time interval between the first and final examination was 7 (2 to 20) days in 9 of the patients. The median (range) gestational age at the first and final examination was 19.0 (15 to 22) weeks ( n = 10) and 20.5 (18 to 24) weeks ( n = 9), respectively. There was significant shortening of the endocervical canal length from the first to the last examination; 12.2 (4 to 20) mm ( n = 10) versus 0.0 (0 to 9.5) mm ( n = 9), p = 0.008. Six patients had membranes at the external cervical os before application of transfundal pressure at the last examination. The one patient lost to ultrasonographic follow-up had a pregnancy loss at 23 weeks of gestation, 6 weeks after a positive response to transfundal pressure. CONCLUSION: In patients at risk for cervical incompetence, shortening of the endocervical canal length in response to transfundal pressure requires treatment with a cervical cerclage because it is associated with progressive cervical changes over 1 to 3 weeks. (Am J Obstet Gynecol 1997;176:634-8.)

The significance of transvaginal ultrasonographic evaluation of the cervix in women treated with emergency cerclage

OBJECTIVE: Our purpose was to determine whether perioperative transvaginal ultrasonographic evaluation of the incompetent cervix treated with emergency cerclage is predictive of pregnancy outcome. STUDY DESIGN: Twenty-nine women who underwent emergency cerclage at 16 to 26 weeks of gestation had transvaginal ultrasonographic evaluation of the cervix within 48 hours before and after surgery and at least three times thereafter until 28 weeks of gestation. The following measurements were obtained: (1) funnel width, (2) funnel length, (3) endocervical canal length, (4) the distance between the internal and external os, (5) upper cervix (length of closed endocervical canal above the cervical cerclage), (6) lower cervix (endocervical canal length below suture), and (7) cervical index (1 + Funnel length/Endocervical canal length). Values are reported as the median in millimeters, and statistical analysis was performed by use of the Mann-Whitney U test, Wilcoxon signed-rank test, Spearman rank correlation, 2 × 2 contingency tables, and multiple regression analysis with significance set at p < 0.05. RESULTS: Cerclage procedures resulted in significant improvement in postoperative median measurements of funnel width (15 vs 4.0 mm, p < 0.0001), funnel length (29 vs 3 mm, p < 0.0001), and endocervical canal length (2 vs 27 mm, p < 0.0001). There was a significant relationship between gestational age at delivery and the following measurements: preoperative funnel width ( r = -0.51, p = 0.007), postoperative endocervical canal length ( r = 0.39, p = 0.04), length of the lower cervix ( r = 0.39, p = 0.038), and the cervical index ( r = -0.39, p = 0.038). An upper cervical length <10 mm was a good predictor of delivery before 36 weeks of gestation, sensitivity 85.7% (12/14), specificity 66.7% (10/15), positive predictive value 70.6% (12/17), negative predictive value 83% (10/12), and Fisher's exact p = 0.008. Postoperatively all patients had upper cervical lengths <10 mm by 28 weeks of gestation. Preoperative digital assessments of cervical dilatation before surgery did not correlate with gestational age at birth ( r = -0.031, p = 0.36). CONCLUSIONS: In cases of cervical incompetence treated with emergency cerclage, perioperative transvaginal ultrasonographic assessment of the cervix reveals that the procedure results in improved ultrasonographic status of the cervix and that the ultrasonographic cervical findings before and after surgery correlate with pregnancy outcome. (Am J Obstet Gynecol 1996;175:471-6.)