Mid-trimester Cervical Shortening Research Articles

Diabetes Mellitus as a Risk Factor for Spontaneous Preterm Birth in Women with a Short Cervix after Ultrasound-Indicated Cerclage.

Background: Preterm birth (PTB) is a significant challenge in contemporary obstetrics, affecting over one in ten infants worldwide and accounting for 75% of perinatal mortality. Short cervical length during mid-trimester is well known to be associated with an increased risk of spontaneous preterm birth (sPTB). Ultrasound-indicated cerclage (UIC) is recommended to prevent sPTB in women with a short cervix at mid-trimester and a history of sPTB. Objectives: This retrospective observational study aimed to examine the impact of diabetes and obesity on the occurrence of sPTB in women who underwent UIC due to mid-trimester cervical shortening. Methods/Results: The analysis revealed that cervical length at the time of operation, preoperative erythrocyte sedimentation rate levels, and diabetes were independent risk factors for sPTB. Additionally, the presence of diabetes, particularly when combined with obesity, significantly elevated the risk of sPTB. Women with pregestational diabetes or those requiring insulin treatment had a higher propensity for preterm delivery compared to those with gestational diabetes managed through diet control alone. Conclusions: These findings emphasize the importance of considering maternal metabolic factors, such as diabetes and obesity, in women with a short cervix when planning for UIC and highlight the crucial role of optimizing maternal glucose control and weight management in reducing the risk of sPTB.

EMG provides insights into preterm birth: Mid-trimester cervical shortening is associated with abnormal myometrial activation

Risk of preterm birth (PTB) increases with shortening cervical length (CL) in the mid-trimester; yet, pathophysiology is poorly understood. Uterine electromyography (uEMG) is a novel technology, which offers nuanced assessment of myometrial signaling, not observable with legacy tocodynamometry. We aimed to characterize uterine bioelectrical activity in pregnant patients with short cervical lengths (CL) in the mid-trimester.

579 Mid-trimester cervical shortening and its association with adverse neonatal outcomes in twin gestations

A shortened mid-trimester transvaginal cervical length (TVCL) is the strongest predictor of premature birth in twin gestations. Our objective was to determine the relative frequencies of adverse neonatal outcomes associated with a range of mid-trimester TVCL measurements. Retrospective cohort study of 403 twin gestations (806 neonates) delivered between 2003 and 2010. TVCL measurements were routinely obtained between 18-24 weeks’ gestation and the shortest of 3 measurement acquired was used to categorize each woman into the following cohorts: 0-10mm (n=21), 11-20mm (n=32), 21-30mm (n=61), 31-40mm (n=126), and > 40mm (n=163; referent group). Rates of individual and composite adverse neonatal outcomes were compared between the TVCL categories. Poisson regression with robust error variance was used to calculate the adjusted relative risk (aRR) and 95% confidence interval (CI) for composite adverse neonatal outcomes controlling for confounders. Shortened mid-trimester TVCL was strongly associated (p<.001) with composite neonatal morbidity/mortality with 89.5% of women with a TVCL 0-10mm experiencing a serious adverse outcome in at least one twin or 77.8% in both twins (Table 1). Compared to women with a TVCL >40 mm, those with a TVCL 0-10 mm had a significantly greater risk of experiencing composite neonatal morbidity/mortality (aRR: 1.6, CI: 1.2-2.2). A shortened mid-trimester TVCL was also significantly associated (p<.001) with each individual primary neonatal morbidity except Grade III/IV IVH and every secondary neonatal outcome except hypoglycemia (Table 2). Every woman with a TVCL 0-10mm had at least one baby admitted to the NICU with a median LOS of 33 days. Shortening of the TVCL in twin pregnancies is significantly associated with both individual and composite neonatal morbidity/mortality, NICU admission, and neonatal LOS. These data should be useful in more precisely counseling women carrying twins regarding neonatal implications of a shortened TVCL in mid pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pregnancy duration with use of 17-α-hydroxyprogesterone caproate in a retrospective cohort at high risk of recurrent preterm birth

The use of 17-α-hydroxyprogesterone caproate for the prevention of recurrent spontaneous preterm birth has become widespread, yet there are conflicting data regarding its efficacy. We sought to determine whether administration of 17-α-hydroxyprogesterone caproate was associated with pregnancy prolongation in women at a high risk of recurrent spontaneous preterm birth. This is a retrospective cohort study of women with singleton pregnancies and a history of spontaneous preterm birth at <37 weeks' gestation who received care at our academic tertiary care center between 2009 and 2019. We included women with gestations that progressed beyond 16 weeks. We excluded those who underwent history-indicated cerclage placement. We first examined the characteristics of women who received 17-α-hydroxyprogesterone caproate and those who did not. Covariates with a P value of ≤.2 on this univariate analysis were considered for incorporation into a Cox proportional hazards model to assess the association between 17-α-hydroxyprogesterone caproate use and pregnancy prolongation up to 35 weeks. Of 861 women included in the study, 570 (66.2%) reported non-Hispanic black racial identity, 237 (27.5%) lived in zip codes with a high infant mortality rate (≥12.1/1000 infants), 287 (33.3%) had more than 1 previous spontaneous preterm birth, 372 (43.2%) had previous spontaneous preterm birth at ≤32 weeks' gestation, and 242 (28.1%) were smokers. Here, 152 pregnancies (17.6%) were complicated by spontaneous preterm birth at <35 weeks' gestation. Factors independently associated with pregnancy duration up to 35 weeks included weight gain of <0.2 kg (0.5 lb) per week, first recorded weight of <98 kg (215 lb), obstetrical history, non-Hispanic white racial identity, lack of prenatal care, and vaginal bleeding. Gestational age at delivery was also independently associated with interventions typically employed for midtrimester cervical shortening and/or dilation, including ultrasound- and examination-indicated cerclage, pessary placement, and vaginal progesterone administration. The use of 17-α-hydroxyprogesterone caproate was not associated with pregnancy prolongation (adjusted hazard ratio, 0.83; 95% confidence interval, 0.60-1.15). The risk profile of our cohort is similar to that of women enrolled in the landmark trial that led to the Food and Drug Administration's approval of 17-α-hydroxyprogesterone caproate. Despite the high-risk nature of the pregnancies examined, we found no association between use of the medication in daily clinical practice and pregnancy prolongation up to 35 weeks. This finding adds to the mounting evidence that calls into question the drug's efficacy in reducing the risk of recurrent spontaneous preterm birth.

Mid-trimester cervical length not associated with HIV status among pregnant women in Botswana

HIV-infected women on antiretroviral therapy have a higher risk of preterm birth than HIV-uninfected women in Botswana. To better understand the mechanism for preterm birth among HIV-infected women, we evaluated whether mid-trimester cervical length differed by HIV status as cervical shortening is associated with an increased risk for preterm birth. We conducted a prospective cohort study among pregnant women receiving care at the Scottish Livingstone Hospital in Molepolole, Botswana. Consecutive women referred for routine obstetrical ultrasound were consented and enrolled if between 22w0d and 24w6d by ultrasound biometry. Blinded to maternal HIV status, an obstetrician measured transvaginal cervical length using standardized criteria. Cervical length, as well as the proportion of women with a short cervix (<25mm), were compared among HIV-infected and HIV-uninfected women. The acceptability of transvaginal ultrasound was also evaluated. Between April 2016 and April 2017, 853 women presenting for obstetric ultrasound were screened, 187 (22%) met eligibility criteria, and 179 (96%) were enrolled. Of those enrolled, 50 (28%) were HIV-infected (86% on antiretroviral therapy), 127 (71%) were HIV-uninfected, and 2 (1%) had unknown HIV status. There was no significant difference in mean cervical length between HIV-infected and HIV-uninfected women (32mm vs 31mm, p = 0.21), or in the proportion with a short cervix (10% vs 14%, p = 0.44). Acceptability data was available for 115 women who underwent a transvaginal ultrasound exam. Of these, 112 of 115 (97%) women deemed the transvaginal scan acceptable. The increased risk of preterm birth observed among HIV-infected women receiving antiretroviral therapy in Botswana is unlikely associated with mid-trimester cervical shortening. Further research is needed to understand the underlying mechanism for preterm birth among HIV-infected women.

Impact of additional risk factors on the incidence of preterm delivery among pregnant women diagnosed with short cervix

ObjectiveAdditional risk factors for preterm delivery in pregnant women with cervical shortening are not fully understood; however, mid-trimester cervical shortening is accepted as a risk factor for preterm delivery. This study aimed to identify risk factors associated with subsequent preterm delivery among patients with short cervix detected after late mid-trimester. Materials and methodsThis was a retrospective study of medical data from a single perinatal tertiary facility. We identified 134 asymptomatic women with singleton pregnancies where cervical shortening (≤25 mm) was detected during routine universal screening at 22–33 weeks. Statistical analyses were conducted to identify causal relationships between the incidence of preterm delivery and known risk factors for preterm delivery. ResultsIncidence of preterm delivery was 27.6% (37/134) and preterm premature rupture of membrane was preceded in 46.0% (17/37) of the women with preterm delivery. Using logistic regression analysis, we identified uterine contractions [aOR 4.25, 95% confidence intervals (CI):1.68–12.1] and increased C-reactive protein (CRP) and increased white blood cell (WBC) in blood test (CRP: aOR 3.45, 95% CI:1.50–9.71; WBC: aOR 1.28, 95% CI: 1.08–1.55) as risk factors which significantly increased the risk of preterm delivery among women diagnosed with short cervix. Preterm delivery occurred in 91% of women positive for both uterine contractions and CRP >0.5 mg/dl. ConclusionsUterine contraction and elevated CRP were additional risk factors for preterm delivery among women with short cervix. These results might be clinically useful to evaluate subsequent risk for preterm delivery in asymptomatic pregnant women presenting with short cervix in mid-pregnancy.

407: Effect of intramuscular progesterone on the cervicovaginal microbiome in high-risk women with midtrimester cervical shortening

407: Effect of intramuscular progesterone on the cervicovaginal microbiome in high-risk women with midtrimester cervical shortening

89: Longitudinal changes in the cervicovaginal microbiome in high-risk women who experience midtrimester cervical shortening

89: Longitudinal changes in the cervicovaginal microbiome in high-risk women who experience midtrimester cervical shortening

Comparison of management options for twin pregnancies with cervical shortening

Objective To compare the effectiveness of expectant management (EM), cervical cerclage (CC) and vaginal progesterone (VP) in decreasing the rate of spontaneous preterm birth in twin gestations with midtrimester cervical shortening. Study design This is a retrospective cohort study comparing pregnancy outcomes of twin gestations with midtrimester cervical shortening, defined as a cervical length (CL) on routine transvaginal ultrasound between 15 weeks 0 days and 24 weeks 6 days gestation of <2.5 cm, managed with either EM, CC or VP. Women were categorized by final management strategy. Primary outcome was gestational age at delivery. Secondary outcomes included latency period (defined as number of weeks between a diagnosis of cervical shortening and delivery), gestational age at delivery <32 weeks, mode of delivery, perinatal death, neonatal birthweight and rate of chorioamnionitis. Subanalysis of women with a CL < 1.5 cm was also performed. Logistic regression was used to identify predictors of delivery <32 weeks, controlling for potential confounders. Results Between January 2006 and July 2016, 64 pairs of twins with midtrimester cervical shortening were identified, 18 managed with EM (28.1%), 29 CC (45.3%), and 17 VP (26.6%), 52 of which had information regarding delivery outcomes. 90.4% of women delivered prematurely (<37 weeks). Women in the CC group were diagnosed with cervical shortening at a significantly earlier mean gestational age (CC 20.6 ± 1.7 weeks versus EM 22.2 ± 2.9 weeks and VP 22.2 ± 2.0 weeks, p = .02) and had a shorter mean cervical length at the time of diagnosis (CC 1.18 ± 0.7 cm vs. EM 1.56 ± 0.7 and VP 1.95 ± 0.6, p = .002), as compared to those in the EM and VP groups. There was no difference in gestational age at delivery (EM 30.9 ± 5.2 weeks, CC 30.4 ± 4.9 weeks and VP 32.4 ± 4.1 weeks, respectively) or any of the secondary outcomes listed above. Women with a CL <1.5 cm delivered significantly earlier than those with a cervical length ≥1.5 cm (28.4 ± 4.7 weeks vs. 33.2 ± 3.6 weeks, p = .0001). After adjusting for potential confounders, cervical length <1.5 cm, not the management strategy, was the predictor of PTB before 32 weeks in this twin population [AOR 6.56 (95% CI 1.78, 24.20), p = .005]. Conclusion Twin pregnancies with midtrimester cervical shortening are at high risk for preterm delivery, and outcomes were similar regardless of management strategy. Large prospective trials are needed to evaluate the effect of different management strategies for cervical shortening in twins.

The Effect of Intramuscular 17α-Hydroxyprogesterone in Women Screened for Shortened Cervical Length.

This article assesses the effect of weekly intramuscular 17α-hydroxyprogesterone caproate (17P) on midtrimester cervical length (CL) in patients with prior spontaneous preterm birth. Retrospective cohort study of all singletons that underwent CL screening at a single institution from 2011 to 2016. The timing of 17P exposure was assessed. The primary outcome was shortest midtrimester CL. Secondary outcomes included gestational age at delivery, rate of short cervix, cerclage, preterm labor admission, and preterm premature rupture of the membranes (PROM). Multivariable regression analysis was used to model the relationship between 17P exposure and shortest CL, controlling for selected covariates. Of 409 women who underwent screening, 211 received and 198 did not receive 17P prior to the last CL. Rates of short cervix and cerclage were similar between groups. After adjusting for covariates, the shortest CL was significantly shorter in the 17P group. In a secondary analysis, those who received any 17P (n = 293) versus those who did not (n = 116) had higher rates of preterm PROM, preterm labor admission, and cerclage. After controlling for covariates, gestational age at delivery was significantly lower in those receiving 17P. In high-risk patients undergoing CL screening for ultrasound-indicated cerclage, 17P did not prevent midtrimester cervical shortening or prolong gestation.

295: Are cervicovaginal fluid inflammatory mediators associated with mid-trimester cervical shortening in women with prior spontaneous preterm birth?

295: Are cervicovaginal fluid inflammatory mediators associated with mid-trimester cervical shortening in women with prior spontaneous preterm birth?

296: Mid-trimester cervical shortening: before and after cervicovaginal fluid analysis in women with prior spontaneous preterm birth

296: Mid-trimester cervical shortening: before and after cervicovaginal fluid analysis in women with prior spontaneous preterm birth

297: Mid-trimester cervical shortening in women with a prior spontaneous preterm birth: association with quantitative fetal fibronectin concentrations

297: Mid-trimester cervical shortening in women with a prior spontaneous preterm birth: association with quantitative fetal fibronectin concentrations

The relationship between placental histology and cervical length in twin gestations

To evaluate differences in placental lesions in twin pregnancies with and without mid-trimester sonographic cervical shortening. Two groups of women were identified: those with twin gestations and a cervical length <or=2.5 cm measured between 16 and 24 weeks of gestation and those with twin gestations and without evidence of cervical shortening. The placental pathology was then retrospectively reviewed. The placental lesions were categorized as either acute or chronic inflammatory lesions, lesions of malperfusion or coagulopathic lesions. A total of 704 patients with twin gestations were identified. There was significantly more acute chorioamnionitis in patients with cervical shortening but no differences in the frequency of other placental lesions. Placentas with acute inflammatory lesions are significantly more frequent in twin gestations with mid-trimester cervical shortening.