Transvaginal Sonographic Cervical Length Research Articles

Preterm Birth: Screening and Prediction.

Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.

Comparison of Transvaginal Sonographic Cervical Length with Neonatal Outcomes among Pregnant Women Presented with Preterm Premature Rupture of Membrane

Background: Preterm premature rupture of membranes (PPROM) is a significant complication in pregnancy, contributing to maternal, fetal, and neonatal morbidity and mortality. Identifying those at increased risk is crucial to address the problem of prematurity. Transvaginal sonography has emerged as an effective tool for assessing cervical length and predicting preterm delivery. The purpose of the present study was to compare the cervical length measured by transvaginal sonography with neonatal outcomes among pregnant women presented with premature rupture of the membrane. Material & Methods: This comparative cross-sectional study was conducted in the Department of Obstetrics and Gynecology at Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh, from October 2017 to April 2018 for six months. A total of 44 Women who were admitted with premature rupture of membranes after completion of 28 weeks of gestation and before 37 weeks of gestational age, irrespective of their parity and were admitted in labor and antenatal ward were selected as the study population. The study population was divided into two groups designated as Group A where the cervical length of the fetus measured by transvaginal sonography was less than 2 cm and Group B where cervical length was more than 2 cm. Each group had 28 patients respectively. The collected data were analyzed using Statistical Package for Social Sciences (SPSS), version-23, 0. Chi-square tests were performed to compare the results, between the groups where p<0.05 considered, the level of significance with 95% CI. The ethical clearance of this study was obtained from the Institutional Review Board (IRB) of Dhaka Medical College and Hospital (DMCH), Dhaka, Bangladesh. Results: A total number of 44 pregnant women were recruited for this study of which 22 cases were in group A who had the cervical length less than 2 cm and the rest of the 22 cases were in group B who had the cervical length more than 2 cm. The mean age of the patients in Group A is 25.91±3.66 years and in Group B it is 24.32±3.34 years (P >0.05). Mean birth weight was 1.7±0 .37kg in group A and 2.1±0.2kg in group B (p=0.015). In this study, 36.6% baby needed resuscitation in group A whereas only 13.6% needed resuscitation in group B. Regarding neonatal complications in group A, (22.72%) neonates had pneumonia and followed by RDS (36.36%), neonatal sepsis (9.09%), hypoglycemia (9.09%). In group B, 36.36% neonates developed complications which were pneumonia (4.55%), RDS (9.09%), neonatal sepsis (13.63%), hypoglycemia (4.55%) and others (4.55%).Regarding neonatal outcome among the study population, in group A, 1-Min Apgar score <7 was observed in 59.01%) neonates, while in group B, 7(31.81%) was observed(p=0.073). 5- Min Apgar score <7 was observed in 18.18% neonates in group A, while in group B, 4.54% was observed (p=0.158) In group A, (77.27%) neonates needed to be admitted to NICU, while in group B, 36.36% neonates needed to be admitted to NICU(p=0.006). In group A, 77.27% neonates had complications whereas, in group B, only 36.36% neonates had complications (p=0.006). Both in group A and in B, no neonatal death was observed. Conclusion: In conclusion, neonatal complications are significantly associated with the cervical length measured by transvaginal sonography with perinatal outcomes among pregnant women presented with premature rupture of the membrane.

Diagnosis or prognosis? An umbrella review of mid-trimester cervical length and spontaneous preterm birth.

Cervical length is widely used to assess a woman's risk of spontaneous preterm birth (SPTB). To summarise and critically appraise the evidence from systematic reviews on the prognostic capacity of transvaginal sonographic cervical length in the second trimester in asymptomatic women with singleton or twin pregnancy. Searches were performed in Medline, Embase, CINAHL and grey literature from 1 January 1995 to 6 July 2021, including keywords 'cervical length', 'preterm birth', 'obstetric labour, premature', 'review' and others, without language restriction. We included systematic reviews including women who did not receive treatments to reduce SPTB risk. From 2472 articles, 14 systematic reviews were included. Summary statistics were independently extracted by two reviewers, tabulated and analysed descriptively. The ROBIS tool was used to evaluate risk of bias of included systematic reviews. Twelve reviews performed meta-analyses: two were reported as systematic reviews of prognostic factor studies, ten used diagnostic test accuracy methodology. Ten systematic reviews were at high or unclear risk of bias. Meta-analyses reported up to 80 combinations of cervical length, gestational age at measurement and definition of preterm birth. Cervical length was consistently associated with SPTB, with a likelihood ratio for a positive test of 1.70-142. The ability of cervical length to predict SPTB is a prognostic research question; systematic reviews typically analysed diagnostic test accuracy. Individual participant data meta-analysis using prognostic factor research methods is recommended to better quantify how well transvaginal ultrasonographic cervical length can predict SPTB.

The effectiveness of vaginal progesterone in reducing preterm birth in high-risk patients diagnosed with short cervical length after 24 weeks: A retrospective cohort study.

To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.

Comparison of transvaginal sonographic cervical length measurement and Bishop score for predicting labour induction outcomes.

Induction of labour (IOL) is of increasing prevalence worldwide and reliable prediction of its successful outcome is important. Traditional clinical methods for predicting successful IOL outcomes have been supplemented with newer technologies. The aim of this study was to compare transvaginal sonographic (TVS) cervical length measurement with Bishop score in predicting labour induction outcomes. This study included pregnant women with term pregnancy, indication for IOL and unfavourable cervix (Bishop score >6) who had TVS performed prior to IOL. Exclusion critetia were regular contractions, ruptured membranes, non-cephalic presentation, uterine scar and pregnancy complications potentially influencing study outcomes. Outcomes measured were successful IOL defined as achievement of active phase of labour and vaginal delivery. Receiver operating characteristic (ROC) curves were used to determine diagnostic accuracy and sensitivity, specificity, positive and negative predictive values. Statistical significance was defined as p<0.05. Among 112 studied participants, IOL was successful in 101 (90.2%) pregnant women. AUC for Bishop score >2 was 0.831 (95% CI, 0.744-0.917, p<0.001) and for cervical length <30mm 0.679 (95% CI 0.514-0.844, p<0.052). A total of 81 (72.3%) pregnant women delivered vaginally; AUC for Bishop score >2 was 0.754 (95% CI 0.648-0.861, p<0.001) and for cervical length <30mm 0.602 (95% CI 0.484-0.720, p=0.092) which was the only insignificant predictor. Bishop score >2 is a better predictor for both successful IOL and vaginal delivery among induced women with term pregnancy and unfavourable cervix compared to cervical length <30mm.

Transvaginal Sonographic Assessment Following Cervical Pessary Placement for Preterm Birth Prevention.

Background Transvaginal sonographic cervical length assessment identifies pregnant women at risk for preterm birth, and the subsequent placement of a cervical pessary may reduce this risk. The mechanism of action remains uncertain, and postplacement transvaginal sonography may provide further insight into the controversial efficacy of this therapy. Objective To identify any pre- or postplacement sonographic findings associated with preterm delivery following cervical pessary insertion among at-risk women. Materials and Methods This retrospective cohort study utilized electronic medical record and imaging review of all women identified within a large tertiary care health system having undergone cervical pessary placement for preterm birth risk reduction and subsequently delivered between January 2013 (the adoption of this therapeutic option in our system) and March 2017. Indications for cervical pessary placement were guided by maternal–fetal medicine consultation and required a functional cervical length measurement on transvaginal sonography of 25 mm or less. Criteria for initial transvaginal cervical assessment included obstetric history, multiple gestation, and current concern on transabdominal imaging for cervical shortening. All pre- and postplacement transvaginal sonographic measurements were determined for study purposes by re-review of each patient's images by a single author blinded to outcome. Results A total of 88 women were identified as having undergone cervical pessary placement for preterm birth prevention, and 52 yielded complete delivery and imaging data for inclusion. As expected, this was a high-risk population with 51.9% carrying multiple gestations, 32.7% with a history of prior preterm birth, and 11.6% with a history of cervical conization. Although previously hypothesized to represent the mechanism of action, neither the change in uterocervical or intracervical angle was associated with gestational age at delivery. Alternatively, preplacement imaging measurements of cervical funneling, anterior cervical length, and cervical diameter were significantly associated with appropriate pessary placement and decreased preterm birth. Forty-two subjects (80.8%) demonstrated both the anterior and posterior aspects of the cervix within the pessary (appropriate placement) and 95.2% of these subjects demonstrated cervical funneling on initial imaging compared with 25% of those with inappropriate placement ( p = 0.002). Anterior cervical length less than 20 mm and cervical diameter less than 33 mm were associated with preterm delivery less than 28 weeks (16.7 vs. 0%, p = 0.039), and anterior cervical length less than 20 mm was associated with preterm delivery less than 32 weeks (41.7 vs. 10.7%, p = 0.025). Cervical diameter less than 33 mm correlated with an “inappropriately placed” pessary among 83.3% in comparison to 48.7% ( p = 0.048) of women with a cervical diameter less than 33 mm. Significant associations were noted between postplacement functional cervical length measurements and preplacement anterior cervical length ( p = 0.001) and cervical diameter ( p = 0.012). Conclusion Contrary to current thinking, no significant changes in uterocervical and intracervical angle following cervical pessary placement were identified. However, preplacement sonographic measurement of funneling, anterior cervical length, and cervical diameter are predictive of appropriate pessary placement and extreme preterm birth. These may represent markers for candidacy of cervical pessary placement. Postplacement transvaginal sonography represents an important tool to assess potential efficacy of this therapeutic modality, and further investigation of these factors is warranted.

Cervical Length Monitoring in Placenta Previa to Predict Emergency Cesarean Section for Antepartum Hemorrhage [06M

INTRODUCTION: Placenta previa can cause significant obstetric hemorrhage and present as grave emergency, leading to adverse maternal and perinatal outcome. We conducted a prospective observational study to determine if cervical length (CL) ≤3 cm correlates with emergency Cesarean section (CS) for Antepartum hemorrhage (APH). METHODS: Transvaginal sonographic CL was measured for women with placenta previa beyond 26 weeks and then at two weekly intervals. Emergency CS due to APH, APH episodes, gestation at delivery and baby’s birth weight were compared between women with CL ≤3 cm (group 1) and CL &gt;3 cm (group 2), measured at the time of recruitment. The study was approved by the local Institutional Ethics Committee. RESULTS: Seventy-one women were included, out of which seven delivered vaginally and 64 underwent CS. More women required emergency CS in group 1 (19/32, 59.4%) than in group 2 (14/32, 43.8%) (P=.211). With serial monitoring, short CL ≤3 cm was significantly associated with emergency CS within two weeks (21/32 (65.6%) vs. 12/32 (37.5%), P=.024). Women with short CL ≤3 cm delivered earlier (35.4±2.0 weeks vs. 36.1±2.3 weeks in group 1 &amp;2 respectively, P=.005). Number of APH episodes was higher in group 1 as compared to group 2 (2.2±1.4 vs. 1.5±1.4, P=.024). Women with CL &gt;3 cm delivered neonates with higher birth weight as compared to those with CL ≤3 cm (2.56±0.6 kg vs. 2.3±0.5 kg, P=.046). CONCLUSION: Cervical length ≤3 cm is associated with more APH episodes, lower gestation and baby weight at birth in women with placenta previa. Serial monitoring of CL may predict need for emergency CS and help plan admission and delivery.

Prediction of time of delivery using cervical length measurement in women with threatened preterm labor

Objective To evaluate the use of transvaginal (TV) sonographic cervical length (CL) measurement alone in predicting time of delivery in women who present in threatened preterm labor. Methods A retrospective cohort study at Royal Brisbane and Women’s Hospital of all women who presented between 22 weeks and 0 days and 35 weeks and six-day gestation in threatened preterm labor and were admitted for ongoing management including a TV sonographic CL measure. The accuracy of CL for predicting time of delivery was compared between women with a short cervix (CL < 25 mm) and those with a normal cervix (CL ≥25 mm). The predictive accuracy of CL for spontaneous preterm delivery was analyzed with different outcome-specific thresholds. Results One hundred and forty-six women with threatened preterm labor met the inclusion criteria; of which 74 (50.7%) had a short cervix and 72 (49.3%) had a normal cervix. The group with short cervix were more likely to deliver prematurely before 37-week gestation, as well as a shorter time interval between initial presentation and delivery and delivery within 14 days from presentation (p = .0002, p = .0001, and p = .0001, respectively). Similarly, with respect to the area under the receiver operator characteristic curves, CL measurement was found to be significant for time of delivery before or after 37 weeks (p < .0001), preterm delivery before 34 (p = .0003) and 31 (p < .0001) weeks; and preterm delivery within 14 days from presentation (p < .0001). Cervical length measurement has a high negative predictive value ranging from 94.9 to 97.1% depending on the different CL threshold used. Conclusions Cervical length measurement at the time of presentation was significantly associated with the risk of preterm delivery in women presenting with threatened preterm labor and a short cervix. Cervical length measurement was also helpful in predicting time of delivery within 14 days from presentation. The negative predictive value and predictive accuracy of CL as a single measure were of significance.

EP03.05: Transvaginal sonographic cervical length in 11–14 weeks of gestation in a low‐risk population and risk of spontaneous preterm delivery

EP03.05: Transvaginal sonographic cervical length in 11–14 weeks of gestation in a low‐risk population and risk of spontaneous preterm delivery

Effectiveness and Accuracy of Tests for Preterm Delivery in Symptomatic Women: A Systematic Review

This study systematically reviewed evidence on the effectiveness and accuracy of predictive tests for preterm delivery among symptomatic women. The study included English-language systematic reviews (SRs) on any predictive test for preterm delivery among symptomatic women and primary studies for placental alpha-microglobulin-1. PubMed, Wiley Cochrane Library, the Centre for Reviews and Dissemination Database, the National Guidelines Clearinghouse, and the TRIP database were searched for SRs, PubMed and PubMed Central via the Wiley Cochrane Library were searched for primary studies. One reviewer performed study selection, with input from a second reviewer when needed. One reviewer appraised study quality and extracted: study characteristics (i.e., country, funding source, study design [primary studies] or synthesis method [SRs], study appraisal method [SRs]), population characteristics, index test(s) and cut-off points used, comparator(s) or reference standard(s), and outcomes. A second reviewed a random 10% sample. The authors synthesized the findings narratively. Of 451 unique records, the review included 22 (17 SRs, five primary studies). For effectiveness, there was evidence for use of transvaginal sonographic cervical length assessment (15-25 mm cut point) in reducing incidence of preterm delivery at <37 weeks (relative risk 0.64; 95% CI 0.44-0.94, one SR of three trials; n = 287) but lack of support for cervicovaginal fetal fibronectin. In terms of accuracy, one high-quality study within a best-evidence SR showed that cervical length measurement was useful to predict delivery within 48 hours (LR+ 6.43, 95% CI 5.17-8.00; LR- 0.03, 95% CI 0.00-0.42; n = 510) and 7 days (LR+ 8.61, 95% CI 6.65-11.14; LR- 0.03, 95% CI 0.00-0.18; n = 510). Accuracy of placental alpha-microglobulin-1 testing was not supported for most end points. In conclusion, some evidence supports the effectiveness of cervical length as a predictor of preterm delivery in symptomatic women. Evidence for most tests is limited in quality and quantity.

Effect of vaginal progesterone and cervical cerclage in twin pregnancy and their perinatal outcome

Objective The aim of this study was to eva lu ate the effectiveness of vaginal progesterone, cervical cerclage, and combination in preventing preterm labor (PTL) in twin pregnancy and impact on perinatal outcome. Background Several studies showed the efficacy of vaginal progesterone and cervical cerclage or both in prevention of PTL in twin pregnancy. Patients and methods A sample size of 75 patients has been taken from outpatient clinic at Menoufia University Hospital. All fulfilled eligibility criteria of having a twin pregnancy with a history of spontaneous PTL, a sonographic short cervical length of less than 25 mm in mid-trimester. The participants were randomly assigned to three groups: group 1 (N = 25) received vaginal progesterone; group 2 (N = 25) were remedied with cervical cerclage; and group 3 (N = 25) received both vaginal progesterone and cervical cerclage. The primary outcome measure was spontaneous delivery between 34 and 37 weeks of gestation. Secondary outcomes were delivery before 34 weeks of gestation. Results There were no significant differences between the three studied groups concerning their demographic data. There were no statistical significant differences between the three studied groups regarding the transvaginal sonographic cervical length (P > 0.05). There was a statistically significant higher gestational age in the combination group than the progesterone group or cerclage group (P < 0.001). Comparison between progesterone and cerclage groups did not reach statistical significance (P=−0.85). Both demonstrated significantly lower birth weights, lower APGAR scores, and a higher NICU admission rate than in the combination group (P < 0.001). Conclusion Combination of vaginal progesterone and cervical cerclage can prevent PTL in twin pregnancy and improve perinatal morbidity and mortality.

Transvaginal sonographic cervical length in first and second trimesters in a low-risk population: a prospective study.

To assess cervical length (CL) longitudinally between the first and second trimesters and to determine the proportion of women with short CL. The study also aimed to assess if women with short CL at 19-24 weeks' gestation could be identified at the time of combined first-trimester screening (cFTS) at 11-14 weeks' gestation, in order to determine the potential value of implementation of CL screening for prediction of preterm delivery in a Danish population. This was a prospective longitudinal study of women with singleton pregnancy attending three University Hospitals in Denmark for combined first-trimester screening from 1 November 2013 to 1 December 2014. Exclusion criteria were multiple pregnancy, uterine anomaly, cerclage or progesterone treatment at inclusion. CL was measured on transvaginal sonography at 11-14 weeks (Cx1), 19-21 weeks (Cx2) and 23-24 weeks (Cx3), by trained operators as a straight line from external to internal os. Women with CL ≤ 25 mm were referred to a maternal-fetal medicine specialist for treatment according to a standardized management protocol. Of the 4904 eligible women, 3477 (71%) participated and had Cx1 recorded. Of those, 3232 (93.0%) had CL measured on all three scans. Median Cx1 was 37 mm, and median Cx2 and Cx3 were 40 mm. The proportion of women with CL ≤ 25 mm increased with gestational age, from 0.41% (95% CI, 0.19-0.62%) at Cx1 to 1.79% (95% CI, 1.34-2.24%) at Cx3. In total, the proportion of women with second-trimester CL (Cx2 or Cx3) ≤ 25 mm was 2.0% (n= 67), of which 38.8% (n= 26) were detected at 19-21 weeks. The probability of short CL between 19 and 24 weeks was greater for those with shorter first-trimester CL. It was nearly nine-fold higher for women with Cx1 ≤ 25 mm compared with Cx1 ≥ 35 mm (17% vs 2%). The performance of Cx1 for prediction of short second-trimester CL was 50% at a 10% false-positive rate. It was found that more than 1500 women would need to be screened for short CL at 19-21 weeks to prevent one case of spontaneous preterm delivery before 34 weeks in a population such as the one in this study. There is an association between first-trimester CL and risk of short cervix in the second trimester. Once short CL was observed, risk of preterm delivery was greatly increased. However, whether universal CL screening should be implemented in this low-risk population depends on cost-benefit analysis taking into account the low proportions of women with short CL and at risk for preterm delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Transvaginal Sonographic Cervical Length Measurement as Predictor of Preterm Delivery

The present study entitled, “Transvaginal Sonographic cervical length measurement as predictor of Preterm delivery” was carried out on 150 cases of primiparas who attended the Govt. Medical College, Hospital, Nagpur. The transvaginal ultrasonographic cervical length was measured at 18 -20 weeks. These cases were followed at 24 weeks and 28 to 30 weeks for pregnancy outcome as abortion, preterm labour or full term delivery. The study was carried out to correlate the outcome of pregnancy (preterm delivery) with the transvaginal cervical length measured serially at 18-20 wks, 24 wks & 28-30 wks. The mean cervical length was 41.9 at 18-20 weeks, 40.09 at 24 weeks and 37.41 at 28 to 30 weeks. The mean cervical length in patients who had preterm delivery was 22.67 at 18 to 20 weeks, 24 at 24 weeks and 18.50 at 28-30 weeks compared to 42.03, 40.3 and 32.41 respectively in those who had full term delivery. This difference was significant. The cervical length of

Transvaginal sonographic assessment of cervix in prediction of admission to delivery interval in preterm premature rupture of membranes

Objective: To assess the usefulness of cervical parameters measured by transvaginal sonography, that is, cervical length and posterior cervical angle, in predicting the admission to delivery interval in women with preterm rupture of membranes.Methods: This prospective study was conducted in a tertiary care centre in South India. Women with preterm premature rupture of membranes at 28–34 weeks, confirmed clinically, not in labour and presenting within 24 hours to hospital were included. We evaluated the relationship between latency interval and transvaginal sonographic parameters (cervical length and posterior cervical angle), parity, age, Amniotic Fluid Index (AFI), total leucocyte count at admission using Cox proportional hazards model.Results: Mean time interval between the membrane rupture and delivery was 96.9 h. Majority of the women (63.8% (n = 51)) delivered within 48 hours. Transvaginal sonographic cervical length was not shown to be associated with latency interval (p = .559), whereas. Posterior cervical angle was shown to be significantly associated with the interval (hazard ratio 1.03, 95%CI: 1.01–1.06; p = .003)Conclusions: Posterior cervical angle assessment using transvaginal sonography is an useful tool in the assessing the latency interval in women with preterm premature rupture of membranes (PPROM). This could help in counselling and planning timely referral to centres with neonatal facilities.

An Educational Intervention to Improve Physician Confidence and Knowledge About Transvaginal Sonographic Cervical Assessment in Obstetric Patients

Local Mentor: David Forstein, DO APGO Advisors: Jody Steinauer, MD, MAS, and Sonya Erickson, MD PURPOSE: To evaluate the effect of an educational intervention about transvaginal sonographic cervical length (CL) measurement on obstetrics and gynecology residents' confidence and knowledge. BACKGROUND: Preterm labor admissions are costly. Transvaginal ultrasound measurement of CL has a high negative predictive value for preterm delivery, and can help triage patients with symptoms. Education about transvaginal CL measurement may increase use of this screening tool when triaging patients with preterm labor symptoms. METHODS: This was a before and after study of OB/Gyn residents at a single institution. The intervention consisted of an educational module adapted from a preexisting module from AIUM. Nine pre- and post-test questions evaluated knowledge. Residents were asked about their confidence with each answer and in doing CL measurements. Chi-squared tests were used to compare proportions and ordinal data, and Wilcoxon rank sum test the proportion of correct answers. RESULTS: Twenty-one residents participated. The proportion of residents answering 89% or more of the questions correctly increased from 5% before to 81% (P&lt;.01). The level of confidence about answers to knowledge-based questions about the technique increased significantly, (P&lt;.01) however confidence in doing CL measurement did not change, with 52% of residents saying they were not confident before and 38% after the intervention (P=.4). DISCUSSION: An educational module can increase knowledge about the utility and performance of cervical length measurement, but does not change confidence in doing the measurement. Future efforts should include curricula to teach the actual measurement.

ACES: Accurate Cervical Evaluation With Sonography.

Transvaginal sonographic cervical length screening is an important tool for the evaluation of preterm labor. However, a structured curriculum is lacking in obstetrics and gynecology residency programs. The Accurate Cervical Evaluation with Sonography (ACES) program was developed to address this deficiency and combines an online didactic course with a standardized performance assessment of live scans. We sought to evaluate the effectiveness of the ACES program to teach residents sonographic cervical length assessment. All obstetrics and gynecology residents at our institution were invited to participate from 2012 to 2013. The program consisted of an initial supervised transvaginal cervical evaluation, an online didactic course and written examination, and 5 subsequent supervised scans. The instructor performed an independent cervical length measurement at each encounter. The primary outcome was the difference in cervical length measurement between the resident and instructor. We hypothesized that this difference would decrease over time. At each visit, a 10-item checklist was used for skill assessment. Comparisons of checklist scores over time were also performed. Seventeen of 20 residents completed at least some of the training, and 10 completed the entire program. The median difference in cervical length measurement between residents and instructors at posttests 3, 4, and 5 improved significantly compared to the pretest scan (all P ≤ .02). Similarly, the checklist scores improved over time (all P ≤ .0008). Transvaginal cervical sonography is an important tool in the evaluation of preterm labor. The ACES program provides residents a structured curriculum for cervical evaluation and supervisors a standardized means of evaluating trainees' skills.

Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications

Vaginal progesterone administration to women with a sonographic short cervix is an efficacious and safe intervention used to prevent preterm birth and neonatal morbidity and mortality. The clinical and public health implications of this approach in the United States have been critically appraised and compared to other therapeutic interventions in obstetrics. Vaginal progesterone administration to women with a transvaginal sonographic cervical length (CL) ≤25 mm before 25 weeks of gestation is associated with a significant and substantial reduction of the risk for preterm birth from <28 to <35 weeks of gestation, respiratory distress syndrome, composite neonatal morbidity and mortality, admission to the neonatal intensive care unit, and mechanical ventilation. These beneficial effects have been achieved in women with a singleton gestation, with or without a history of spontaneous preterm birth, and did not differ significantly as a function of CL (<10 mm, 10-20 mm, or 21-25 mm). The number of patients required for treatment to prevent 1 case of preterm birth or adverse neonatal outcomes ranges from 10-19 women. The number needed to screen for the prevention of 1 case of preterm birth before 34 weeks of gestation is 125 women, and 225 for the prevention of 1 case of major neonatal morbidity or neonatal mortality. Several cost-effectiveness and decision analyses have shown that the combination of universal transvaginal CL screening and vaginal progesterone administration to women with a short cervix is a cost-effective intervention that prevents preterm birth and associated perinatal morbidity and mortality. Universal assessment of CL and treatment with vaginal progesterone for singleton gestations in the United States would result in an annual reduction of approximately 30,000 preterm births before 34 weeks of gestation and of 17,500 cases of major neonatal morbidity or neonatal mortality. In summary, there is compelling evidence to recommend universal transvaginal CL screening at 18-24 weeks of gestation in women with a singleton gestation and to offer vaginal progesterone to those with a CL ≤25 mm, regardless of the history of spontaneous preterm birth, with the goal of preventing preterm birth and neonatal morbidity and mortality.

Does educational intervention affect resident competence in sonographic cervical length measurement?

Objective: To determine if a structured teaching module improves resident competency in transvaginal sonographic cervical length measurements. Methods: This was a prospective cohort study involving obstetrics and gynecology residents at a single institution. Residents collected 10 transvaginal cervical images from patients with threatened preterm labor presenting to Labor and Delivery. After initial image acquisition, residents participated in a lecture-based teaching module involving a pre- and post-intervention assessment. Following the didactic session, they collected 10 additional images. All the images were scored independently by two Maternal–Fetal Medicine attending physicians based on the quality and accuracy of the measured cervical length. Pre-and post- intervention test results were compared, as well as pre- and post- intervention image scores. Parametric and nonparametric tests were used as appropriate with p < 0.05 considered significant. Results: Ninety-three percent of the residents (14/15) improved their scores from pre-test to post-test or maintained an already perfect score (p < 0.01). Improvement was most significant with the junior residents. Seventy-nine percent of the residents (11/14) improved their cervical image scores after the educational session. Mean score for total residents was 73.7 + 12.6 pre-intervention and 90.2 + 9.9 post-intervention (p < 0.01) out of a total of 120. Conclusions: There is an improvement in the competence of resident measured cervical lengths via transvaginal ultrasound when a structured educational module is implemented for resident education.

Gestational Age at Cervical Length and Fetal Fibronectin Assessment and the Incidence of Spontaneous Preterm Birth in Twins

To estimate the risk of spontaneous preterm birth in twin pregnancies based on transvaginal sonographic cervical length, fetal fibronectin (fFN) testing, and the gestational age at which these tests were performed. Women with twin pregnancies, cervical length assessment, and fFN testing between 22 weeks and 31 weeks 6 days in a single maternal-fetal medicine practice from 2005 to 2013 were included. All testing was done on asymptomatic women on an out-patient basis. Women with monochorionic monoamniotic twins and twin-twin transfusion were excluded. Logistic regression analysis was used to estimate the risk of spontaneous preterm birth before 35, 32, and 28 weeks. Six hundred eleven patients were included and underwent a total of 2406 cervical length measurements and 2279 fFN tests over the course of the study period. The likelihood values for spontaneous preterm birth before 35, 32, and 28 weeks were 19.1%, 6.3%, and 2.3%, respectively. The risk of spontaneous preterm birth before 35 weeks increased with a decreasing cervical length (coefficient for the log of the odds ratio [OR coefficient], -0.13; P < .01; 95% confidence interval [CI], -0.22 to -0.037), a positive fFN result (OR coefficient, 1.04; P < .01; 95% CI, 0.45 to 1.64), as well as earlier gestational ages at testing (OR coefficient, -0.214; P < .01; 95% CI, -0.33 to -0.10). Similar results were seen for spontaneous preterm birth before 32 and 28 weeks. In asymptomatic patients with twin pregnancies, the cervical length, fFN, and gestational age are all significantly associated with spontaneous preterm birth.

Relationship between interpregnancy interval and cervical length in high-risk women

Objective: Our objective was to evaluate the relationship between the interpregnancy interval (IPI) and next-pregnancy mid-trimester cervical length (CL) in women at high risk for recurrent spontaneous preterm birth (SPTB).Methods: Retrospective review identified high-risk women, defined as a prior SPTB <36 weeks, who began scheduled serial transvaginal sonographic CL screening at 16–18 weeks gestation between December 2008 and November 2010. All CL assessment ended by 226/7 weeks, and weekly 17-α hydroxyprogesterone caproate, 250 mg IM, was recommended to all patients. Details of the prior and current pregnancy were collected, and regression models were used to evaluate the relationship between IPI and CL shortening.Results: One hundred and eight women with singleton gestations and a qualifying SPTB underwent CL screening. The mean (SD) birth gestational age (GA) of the last pregnancy was 25 (10) weeks, the median IPI was 613 (range 49–6038) days, and the mean (SD) delivery GA in the current pregnancy was 36 (5.3) weeks. Linear regression found no significant relationship between the IPI and the GA of the current birth (p = 0.98). There was a weak significant relationship between IPI and shortest CL (p = 0.04). However, after controlling for the GA of the prior pregnancy, this relationship was non-significant (p = 0.13).Conclusions: IPI does not predict next birth outcome or next-pregnancy mid-trimester CL in high-risk women managed with progesterone and ultrasound-indicated cerclage.