The Royal Australian and New ZealandCollege of Obstetricians and Gynaecologists

REWRITE of College Statement C-Obs 27

1st Endorsed: November 2008 Current: July 2012 Review: July 2015

C-Obs 27

Measurement of cervical length for prediction of preterm birth

Introduction There is controversy around the routine ultrasound assessment of the cervix as a means of defining risk of preterm delivery in low risk women.1-3 There is also good data showing that therapeutic intervention (with progesterone) for high risk pregnancies, defined on the basis of a short cervix, have a reduced prevalence of preterm birth.4 This document highlights some of the contemporary issues around this topic. Statement

Accurately measured ultrasound cervical length has an inverse relationship with the risk of preterm birth.1,3,5 Cervical length is most accurately measured by transvaginal ultrasound examination. Most normal ranges / likelihood ratios describing the risk of preterm labour have been calculated using a standardised technique for measurement.6The patient should have an empty bladderand the vaginal probe should be placed in the anteriorfornix, minimising pressure on the cervix as this increases cervical length. The length of the endocervical canal should be measured in a straight line from the internal to the external cervical os. As the cervix is dynamic, three measurements should be made over a five minute period and the shortest measurement reported for clinical use. Other features of the cervix such as funnelling (effacement of the internal aspect of the cervix) and shortening in response to fundal pressure are known to be associated with preterm delivery but do not add significant advantages to predictive modelling when compared to accurate measurement of cervical length alone. Charts describing normal cervical length from 16-36 weeks have been constructed. The median cervical length at 20 weeks is 42mm, the 1st centile is 23mm.7 In singleton pregnancies, having transvaginal assessment of cervical length performed as part of the routine anomaly scan at 20-24 weeks gestation, a short cervix has been shown to be associated with an increased risk of preterm birth.5 A cervical length of 23mm (the first centile) is associated with a 2.8 fold increase in risk of preterm delivery <34 weeks gestation. Cervical lengths of 15mm, 10mm and 5mm have likelihood ratios of 7.3, 13.3 and 24.3 for preterm delivery <34 weeks respectively. There is a growing body of evidence suggesting that interventions, such as progesterone and/ or cervical cerclage may be of benefit for women otherwise considered low risk of preterm birth found to have a short cervix in the midtrimester. Accordingly, it is becoming more common for cervical length assessment to be offered, and performed, at the time of the routine midtrimester ultrasound. Studies have used variable cut-offs to define a high risk cohort that merits therapeutic intervention, but on current evidence using a cut-off of
1 RANZCOGCollege Statement: C-Obs 27

20mm appears to be appropriate. Treatment with progesterone reduces the risk of preterm delivery <34 weeks by 42% and reduces neonatal morbidity. Approximately 11 women need to be treated to prevent one preterm delivery <34 weeks. The use of progesterone is discussed in more detail in a separate RANZCOG clinical guideline (CObs 29b).8 Cervical length assessment among women with risk factors for preterm birth

Meta-analysis has also shown that a subgroup of women who have other risk factors for preterm birth, especially previous history of preterm birth, may benefit from cervical cerclage.9 Further research in this area would be of value. Whilst cervical length also has predictive value in twin pregnancies, there is no clear evidence that therapeutic intervention for those with a short cervix reduces the risk of preterm delivery.10,11 There may, however, be some benefit in recognising multiple pregnancies at risk of preterm delivery, so that appropriate arrangements can be made for care in a tertiary centre with a neonatal unit and so that steroid cover can be arranged. Ultrasound assessment of cervical length can also be useful in defining management for women with a previous history of preterm delivery where an indication for cerclage is unclear and for women attending with symptoms and signs of threatened preterm labour at 24-34 weeks.12,13

References 1. Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, Thom E, McNellis D, Copper RL, Johnson F, Roberts JM. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med 1996; 334: 567-572. 2. Heath VC, Southall TR, Souka AP, Elisseou A, Nicolaides KH. Cervical length at weeks of gestation: prediction of spontaneous preterm delivery. Ultrasound Obstet Gynecol 1998; 12 (5): 312-7. 3. 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 (3): 305-22. 4. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O'Brien JM, Cetingoz E, DaFonseca E, Creasy GW, Klein K, Rode L, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimesterdecreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol 2012; 206: 124.e1-124.e19. 5. Celik E, To M, Gajewska K, Smith GC, Nicolaides KH; Fetal Medicine Foundation Second Trimester Screening Group. Cervical length and obstetric history predictspontaneous preterm birth: development and validation of a model to provideindividualized risk assessment. Ultrasound Obstet Gynecol 2008; 31 (5): 549-54. 6. Heath VC, Southall TR, Souka AP, Novakov A, Nicolaides KH. Cervical length at 23 weeks of gestation: relation to demographic characteristics and previous obstetric history. Ultrasound Obstet Gynecol 1998; 12 (5): 304-11. 7. Salomon LJ, Diaz-Garcia C, Bernard JP, Ville Y. Reference range for cervicallength throughout pregnancy: non-parametric LMS-based model applied to a largesample. Ultrasound Obstet Gynecol 2009; 33 (4): 459-64.
2 RANZCOGCollege Statement: C-Obs 27

8. RANZCOG College Statement C-Obs 29: Progesterone: Use in the Second and Third

Trimester of Pregnancy for the Prevention of Preterm Birth. Available at:

http://www.ranzcog.edu.au/the-ranzcog/policies-and-guidelines/college-statements/422progesterone-use-in-the-second-and-third-trimester-of-pregnancy-for-the-prevention-of-pretermbirth-c-obs-29b.html

9. Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005; 106 (1): 181-9. 10. Conde-Agudelo A, Romero R, Hassan SS, Yeo L. Transvaginal sonographic cervical length for the prediction of spontaneous preterm birth in twin pregnancies: a systematic review and metaanalysis. Am J Obstet Gynecol 2010; 203 (2): 128.e1-12. 11. Klein K, Rode L, Nicolaides KH, Krampl-Bettelheim E, Tabor A; PREDICT Group. Vaginal micronized progesterone and risk of preterm delivery in high-risk twin pregnancies: secondary analysis of a placebo-controlled randomized trial and metaanalysis. Ultrasound Obstet Gynecol 2011; 38 (3): 281-7. 12. Groom KM, Bennett PR, Golara M, Thalon A, Shennan AH. Elective cervical cerclage versus serial ultrasound surveillance of cervical length in a population at high risk for preterm delivery. Eur J Obstet Gynecol Reprod Biol 2004; 112 (2): 158-61. 13. Tsoi E, Fuchs IB, Rane S, Geerts L, Nicolaides KH. Sonographic measurement of cervical length in threatened preterm labor in singleton pregnancies with intact membranes. Ultrasound Obstet Gynecol 2005; 25 (4): 353-6. Links to other College statements (C-Gen 15) Evidence-based Medicine, Obstetrics and Gynaecology
http://www.ranzcog.edu.au/component/docman/doc_download/894-c-gen-15-evidence-based-medicineobstetrics-and-gynaecology.html?Itemid=341

Disclaimer This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have regard to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management must always be responsive to the needs of the individual patient and the particular circumstances of each case. This College statement has been prepared having regard to the information available at the time of its preparation, and each Practitioner must have regard to relevant information, research or material which may have been published or become available subsequently. Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material that may have become available after the date of the statements.

RANZCOGCollege Statement: C-Obs 27