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Am J Perinatol 2023; 40(02): 187-193
DOI: 10.1055/s-0041-1728818
Original Article

Midtrimester Cervical Length in Low-Risk Nulliparous Women for the Prediction of Spontaneous Preterm Birth: Should We Consider a New Definition of Short Cervix?

Paul Guerby 
1   Research Center, CHU de Québec-Université Laval, Québec, Canada
,
Mario Girard
1   Research Center, CHU de Québec-Université Laval, Québec, Canada
,
Geneviève Marcoux
1   Research Center, CHU de Québec-Université Laval, Québec, Canada
,
Annie Beaudoin
1   Research Center, CHU de Québec-Université Laval, Québec, Canada
,
Jean-Charles Pasquier
2   Department of Obstetrics and Gynecology, Université de Sherbrooke, Faculté de Médecine et des Sciences de la Santé 3001, Sherbrooke, Quebec, Canada
,
Emmanuel Bujold 
1   Research Center, CHU de Québec-Université Laval, Québec, Canada
3   Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, Canada
› Author Affiliations Funding This study was supported by the Jeanne and Jean-Louis Levesque Perinatal Research Chair at Université Laval, Québec, Canada. Prof. E.B. holds a Clinician Scientist award from Fonds de recherche du Québec–Santé (FRQS), Québec, Canada. P.G. holds a postdoctoral Award from the FRQS and INSERM (Institut National de la Santé et de la Recherche Médicale).
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Abstract

Objective The study aimed to estimate the predictive value of midtrimester cervical length (CL) and the optimal cut-off of CL that should be applied with asymptomatic nulliparous women for the prediction of spontaneous preterm birth (sPTB).

Study Design This is a prospective cohort study of asymptomatic nulliparous women with a singleton gestation. Participants underwent CL measurement by transvaginal ultrasound between 20 and 24 weeks of gestation. The participants and their health care providers remained blinded to the results of CL measurement. The primary outcomes were sPTB before 35 weeks and sPTB before 37 weeks. Receiver operating characteristics (ROC) curve analyses were performed. Analyses were repeated by using multiples of median (MoM) of CL adjusted for gestational age.

Results Of 796 participants, the mean midtrimester CL was 40 ± 6 mm with a 1st, 5th, and 10th percentile of 25, 29, and 32 mm, respectively. ROC curve analyses suggest that a cut-off of 30 mm was the optimal CL to predict sPTB before 35 weeks (area under the ROC curve [AUC]: 0.70, 95% confidence interval [CI]: 0.56–0.85) and before 37 weeks (AUC: 0.70, 95% CI: 0.59–0.80). Midtrimester CL <30 mm could detect 35% of all sPTB before 35 weeks at a false-positive rate of 5% (relative risk: 9.1, 95% CI: 3.5–23.5, p < 0.001). We observed similar results using a cut-off of CL <0.75 MoM adjusted for gestational age.

Conclusion A midtrimester CL cut-off of 30 mm (instead of 25 mm), or CL less than 0.75 MoM, should be used to identify nulliparous women at high risk of sPTB.

Key Points

  • The optimal CL cut-off for the prediction of sPTB is 30 mm in nulliparous women.

  • In nulliparous women, a midtrimester CL < 30 mm is highly associated with sPTB before 35 and 37 weeks.

  • A midtrimester of CL <30 mm (5th percentile) should define a short cervix in asymptomatic nulliparous women.

Keywords

cervical length - short cervix - screening - preterm birth - nulliparous


Publication History

Received: 18 June 2020

Accepted: 02 March 2021

Article published online:
03 May 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Chawanpaiboon S, Vogel JP, Moller AB. et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health 2019; 7 (01) e37-e46
    CrossrefPubMedGoogle Scholar
  • 2 Moster D, Lie RT, Markestad T. Long-term medical and social consequences of preterm birth. N Engl J Med 2008; 359 (03) 262-273
    CrossrefPubMedGoogle Scholar
  • 3 Zeitlin J, Szamotulska K, Drewniak N. et al; Euro-Peristat Preterm Study Group. Preterm birth time trends in Europe: a study of 19 countries. BJOG 2013; 120 (11) 1356-1365
    CrossrefPubMedGoogle Scholar
  • 4 Kim YM, Bujold E, Chaiworapongsa T. et al. Failure of physiologic transformation of the spiral arteries in patients with preterm labor and intact membranes. Am J Obstet Gynecol 2003; 189 (04) 1063-1069
    CrossrefPubMedGoogle Scholar
  • 5 Hassan SS, Romero R, Vidyadhari D. et al; Pregnant Trial. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011; 38 (01) 18-31
    CrossrefPubMedGoogle Scholar
  • 6 Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Fetal Medicine Foundation Second Trimester Screening Group. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007; 357 (05) 462-469
    CrossrefPubMedGoogle Scholar
  • 7 Medley N, Vogel JP, Care A, Alfirevic Z. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 11: CD012505
    PubMedGoogle Scholar
  • 8 Saccone G, Maruotti GM, Giudicepietro A, Martinelli P. Italian Preterm Birth Prevention (IPP) Working Group. Effect of cervical pessary on spontaneous preterm birth in women with singleton pregnancies and short cervical length: a randomized clinical trial. JAMA 2017; 318 (23) 2317-2324
    CrossrefPubMedGoogle Scholar
  • 9 To MS, Alfirevic Z, Heath VC. et al; Fetal Medicine Foundation Second Trimester Screening Group. Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial. Lancet 2004; 363 (9424): 1849-1853
    CrossrefPubMedGoogle Scholar
  • 10 Wood AM, Dotters-Katz SK, Hughes BL. Cervical cerclage versus vaginal progesterone for management of short cervix in low-risk women. Am J Perinatol 2019; 36 (02) 111-117
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Koullali B, van Zijl MD, Kazemier BM. et al. The association between parity and spontaneous preterm birth: a population based study. BMC Pregnancy Childbirth 2020; 20 (01) 233
    CrossrefPubMedGoogle Scholar
  • 12 Iams JD, Goldenberg RL, Meis PJ. et al; National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. The length of the cervix and the risk of spontaneous premature delivery. N Engl J Med 1996; 334 (09) 567-572
    CrossrefPubMedGoogle Scholar
  • 13 Dude CM, Levine LD, Schwartz N. The impact of previous obstetric history on the risk of spontaneous preterm birth in women with a sonographic Short cervix. Am J Perinatol 2020; 37 (12) 1189-1194
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Dude A, Miller ES. Change in cervical length across pregnancies and preterm delivery. Am J Perinatol 2020; 37 (06) 598-602
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Honest H, Bachmann LM, Coomarasamy A, Gupta JK, Kleijnen J, Khan KS. Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review. Ultrasound Obstet Gynecol 2003; 22 (03) 305-322
    CrossrefPubMedGoogle Scholar
  • 16 Orzechowski KM, Boelig RC, Baxter JK, Berghella V. A universal transvaginal cervical length screening program for preterm birth prevention. Obstet Gynecol 2014; 124 (03) 520-525
    CrossrefPubMedGoogle Scholar
  • 17 Souka AP, Papastefanou I, Pilalis A, Kassanos D, Papadopoulos G. Implementation of universal screening for preterm delivery by mid-trimester cervical-length measurement. Ultrasound Obstet Gynecol 2019; 53 (03) 396-401
    CrossrefPubMedGoogle Scholar
  • 18 Hibbard JU, Tart M, Moawad AH. Cervical length at 16-22 weeks' gestation and risk for preterm delivery. Obstet Gynecol 2000; 96 (06) 972-978
    PubMedGoogle Scholar
  • 19 AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. AIUM practice parameter for the performance of limited obstetric ultrasound examinations by advanced clinical providers. J Ultrasound Med 2018; 37 (07) 1587-1596
    CrossrefPubMedGoogle Scholar
  • 20 Guerby P, Beaudoin A, Marcoux G, Girard M, Pasquier JC, Bujold E. Ultrasonographic transabdominal measurement of uterine cervical length for the prediction of a midtrimester short cervix. Am J Perinatol 2020; DOI: 10.1055/s-0040-1712950.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Carley S, Dosman S, Jones SR, Harrison M. Simple nomograms to calculate sample size in diagnostic studies. Emerg Med J 2005; 22 (03) 180-181
    CrossrefPubMedGoogle Scholar
  • 22 Salomon LJ, Diaz-Garcia C, Bernard JP, Ville Y. Reference range for cervical length throughout pregnancy: non-parametric LMS-based model applied to a large sample. Ultrasound Obstet Gynecol 2009; 33 (04) 459-464
    CrossrefPubMedGoogle Scholar
  • 23 Facco FL, Simhan HN. Short ultrasonographic cervical length in women with low-risk obstetric history. Obstet Gynecol 2013; 122 (04) 858-862
    CrossrefPubMedGoogle Scholar
  • 24 van der Ven J, van Os MA, Kazemier BM. et al. The capacity of mid-pregnancy cervical length to predict preterm birth in low-risk women: a national cohort study. Acta Obstet Gynecol Scand 2015; 94 (11) 1223-1234
    CrossrefPubMedGoogle Scholar
  • 25 van Os MA, van der Ven AJ, Kleinrouweler CE. et al. Preventing preterm birth with progesterone in women with a short cervical length from a low-risk population: a multicenter double-blind placebo-controlled randomized trial. Am J Perinatol 2015; 32 (10) 993-1000
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Esplin MS, Elovitz MA, Iams JD. et al; nuMoM2b Network. Predictive accuracy of serial transvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. JAMA 2017; 317 (10) 1047-1056
    Google Scholar
  • 27 Grobman WA, Thom EA, Spong CY. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network. 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm. Am J Obstet Gynecol 2012; 207 (05) 390.e1-390.e8
    CrossrefPubMedGoogle Scholar
  • 28 Rosenbloom JI, Raghuraman N, Temming LA. et al. Predictive value of midtrimester universal cervical length screening based on parity. J Ultrasound Med 2020; 39 (01) 147-154
    CrossrefPubMedGoogle Scholar
  • 29 Celik E, To M, Gajewska K, Smith GC, Nicolaides KH. Fetal Medicine Foundation Second Trimester Screening Group. Cervical length and obstetric history predict spontaneous preterm birth: development and validation of a model to provide individualized risk assessment. Ultrasound Obstet Gynecol 2008; 31 (05) 549-554
    CrossrefPubMedGoogle Scholar
  • 30 Einerson BD, Grobman WA, Miller ES. Cost-effectiveness of risk-based screening for cervical length to prevent preterm birth. Am J Obstet Gynecol 2016; 215 (01) 100.e1-100.e7
    CrossrefPubMedGoogle Scholar
  • 31 van Os MA, Kleinrouweler CE, Schuit E. et al. Influence of cut-off value on prevalence of short cervical length. Ultrasound Obstet Gynecol 2017; 49 (03) 330-336
    CrossrefPubMedGoogle Scholar
  • 32 Dahlin S, Gunnerbeck A, Wikström AK, Cnattingius S, Edstedt Bonamy AK. Maternal tobacco use and extremely premature birth - a population-based cohort study. BJOG 2016; 123 (12) 1938-1946
    CrossrefPubMedGoogle Scholar
  • 33 Lange S, Probst C, Rehm J, Popova S. National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis. Lancet Glob Health 2018; 6 (07) e769-e776
    CrossrefPubMedGoogle Scholar