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Yan C, Yang Q, Li R, Yang A, Fu Y, Wang J, Li Y, Cheng Q, Hu S. A systematic review of prediction models for spontaneous preterm birth in singleton asymptomatic pregnant women with risk factors. Heliyon 2023; 9:e20099. [PMID: 37809403 PMCID: PMC10559850 DOI: 10.1016/j.heliyon.2023.e20099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/10/2023] Open
Abstract
Backgrounds Spontaneous preterm birth (SPB) is a global problem. Early screening, identification, and prevention in asymptomatic pregnant women with risk factors for preterm birth can help reduce the incidence and mortality of preterm births. Therefore, this study systematically reviewed prediction models for spontaneous preterm birth, summarised the model characteristics, and appraised their quality to identify the best-performing prediction model for clinical decision-making. Methods PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, China Biology Medicine disc, VIP Database, and Wanfang Data were searched up to September 27, 2021. Prediction models for spontaneous preterm births in singleton asymptomatic pregnant women with risk factors were eligible for inclusion. Six independent reviewers selected the eligible studies and extracted data from the prediction models. The findings were summarised using descriptive statistics and visual plots. Results Twelve studies with twelve developmental models were included. Discriminative performance was reported in 11 studies, with an Area Under the Curve (AUC) ranging from 0.75 to 0.95. The AUCs of the seven models were greater than 0.85. Cervical length (CL) is the most commonly used predictor of spontaneous preterm birth. A total of 91.7% of the studies had a high risk of bias in the analysis domain, mainly because of the small sample size and lack of adjustment for overfitting. Conclusion The accuracy of the models for spontaneous preterm births in singleton asymptomatic women with risk factors was good. However, these models are not widely used in clinical practice because they lack replicability and transparency. Future studies should transparently report methodological details and consider more meaningful predictors with new progress in research on preterm birth.
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Affiliation(s)
- Chunmei Yan
- Department of Gynaecology and Obstetrics, Hospital of Lanzhou Jiaotong University, Lanzhou, China
| | - Qiuyu Yang
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Richeng Li
- Department of Gynaecology and Obstetrics, Hospital of Lanzhou Jiaotong University, Lanzhou, China
| | - Aijun Yang
- Department of Gynaecology and Obstetrics, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Yu Fu
- Department of Prenatal Diagnosis Center, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Jieneng Wang
- Department of Cardiovascular Surgery, First Hospital of Lanzhou University, Lanzhou, China
| | - Ying Li
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qianji Cheng
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Shasha Hu
- Department of Obstetrics and Gynecology, First Hospital of Lanzhou University, Lanzhou, China
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Kornete A, Volozonoka L, Zolovs M, Rota A, Kempa I, Gailite L, Rezeberga D, Miskova A. Management of Pregnancy with Cervical Shortening: Real-Life Clinical Challenges. Medicina (B Aires) 2023; 59:medicina59040653. [PMID: 37109611 PMCID: PMC10144538 DOI: 10.3390/medicina59040653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Background and Objectives: Preterm birth is the leading cause of neonatal mortality worldwide and may be responsible for lifelong morbidities in the survivors. Cervical shortening is one of the common pathways to preterm birth associated with its own diagnostic and management challenges. The preventive modalities that have been tested include progesterone supplementation and cervical cerclage and pessaries. The study aimed to assess the management strategies and outcomes in a group of patients with a short cervix during pregnancy or cervical insufficiency. Materials and Methods: Seventy patients from the Riga Maternity Hospital in Riga, Latvia, were included in the prospective longitudinal cohort study between 2017 and 2021. Patients were treated with progesterone, cerclage, and/or pessaries. The signs of intra-amniotic infection/inflammation were assessed, and antibacterial therapy was given when the signs were positive. Results: The rates of PTB were 43.6% (n = 17), 45.5% (n = 5), 61.1% (n = 11), and 50.0% (n = 1) in progesterone only, cerclage, pessary, and cerclage plus pesssary groups, respectively. The progesterone therapy was associated with a reduced preterm birth risk (x2(1) = 6.937, p = 0.008)), whereas positive signs of intra-amniotic infection/inflammation significantly predicted the risk of preterm birth (p = 0.005, OR = 3.82, 95% [CI 1.31–11.11]). Conclusions: A short cervix and bulging membranes, both indicators of intra-amniotic infection/inflammation, are the key risk factors in preterm birth risk predictions. Progesterone supplementation should remain at the forefront of preterm birth prevention. Among patients with a short cervix and especially complex anamnesis, the preterm rates remain high. The successful management of patients with cervical shortening lies between the consensus-based approach for screening, follow-up, and treatment on the one side and personalising medical therapy on the other.
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Affiliation(s)
- Anna Kornete
- Department of Obstetrics and Gynaecology, Riga Stradins University, LV-1007 Riga, Latvia
- Riga Maternity Hospital, LV-1013 Riga, Latvia
- Correspondence:
| | - Ludmila Volozonoka
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, LV-1007 Riga, Latvia
| | - Maksims Zolovs
- Department of Statistics, Riga Stradins University, LV-1007 Riga, Latvia
- Institute of Life Sciences and Technologies, Daugavpils University, LV-5401 Daugavpils, Latvia
| | - Adele Rota
- Department of Obstetrics and Gynaecology, Riga Stradins University, LV-1007 Riga, Latvia
- Riga Maternity Hospital, LV-1013 Riga, Latvia
| | - Inga Kempa
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, LV-1007 Riga, Latvia
| | - Linda Gailite
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, LV-1007 Riga, Latvia
| | - Dace Rezeberga
- Department of Obstetrics and Gynaecology, Riga Stradins University, LV-1007 Riga, Latvia
- Riga Maternity Hospital, LV-1013 Riga, Latvia
| | - Anna Miskova
- Department of Obstetrics and Gynaecology, Riga Stradins University, LV-1007 Riga, Latvia
- Riga Maternity Hospital, LV-1013 Riga, Latvia
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Silva TV, Borovac-Pinheiro A, Cecatti JG, Mol BW, Silva Costa F, França MS, Souza RT, Devlieger R, Passini R, Carvalho Pacagnella R. Association between cervical length and gestational age at birth in singleton pregnancies: a multicentric prospective cohort study in the Brazilian population. Reprod Health 2023; 20:47. [PMID: 36949530 PMCID: PMC10035243 DOI: 10.1186/s12978-022-01557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/21/2022] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Short cervical length measured during the second trimester of pregnancy is an important risk factor for spontaneous preterm birth (sPTB). The aim of this study is to identify the association between mid-pregnancy cervical length (CL) and gestational age at birth in asymptomatic singleton pregnant women. METHODS This is a prospective cohort study involving singleton pregnant women who participated in the screening phase of a Brazilian multicenter randomized controlled trial (P5 trial) between July 2015 and March 2019. Transvaginal ultrasound to measure CL was performed from 18 to 22 + 6 weeks. Women with CL ≤ 30 mm received vaginal progesterone (200 mg/day) until 36 weeks' gestation. For this analysis we considered all women with CL ≤ 30 mm receiving progesterone and a random selection of women with CL > 30 mm, keeping the populational distribution of CL. We obtained prognostic effectiveness data (area under receive operating characteristic curve (AUC), sensitivity and specificity and estimated Kaplan-Meier curves for preterm birth using different CL cutoff points. RESULTS We report on 3139 women and identified a negative association between cervical length and sPTB. CL ≤ 25 mm was associated with sPTB < 28, sPTB < 34 and sPTB < 37 weeks, whereas a CL 25-30 mm was directly associated with late sPTB. CL by transvaginal ultrasound presented an AUC of 0.82 to predict sPTB < 28 weeks and 0.67 for sPTB < 34 weeks. Almost half of the sPTB occurred in nulliparous women and CL ≤ 30 mm was associated with sPTB at < 37 weeks (OR = 7.84; 95%CI = 5.5-11.1). The number needed to screen to detect one sPTB < 34 weeks in women with CL ≤ 25 mm is 121 and we estimated that 248 screening tests are necessary to prevent one sPTB < 34 weeks using progesterone prophylaxis. CONCLUSIONS CL measured by transvaginal ultrasound should be used to predict sPTB < 34 weeks. Women with CL ≤ 30 mm are at increased risk for late sPTB.
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Affiliation(s)
- Thais Valéria Silva
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
- CISAM Maternity Hospital, University of Pernambuco, Recife, Brazil
| | - Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
| | - José Guilherme Cecatti
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology, Monash University, Victoria, Australia
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Fabricio Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Southport, Australia
| | - Marcelo Santucci França
- Screening and Prevention of Preterm Birth Sector, Fetal Medicine Discipline, Obstetrics Department, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Renato Teixeira Souza
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
| | - Roland Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Louvain, Belgium
| | - Renato Passini
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
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Bachar G, Attia M, Farago N, Lauterbach R, Khatib N, Zipori Y, Beloosesky R, Weiner Z, Vitner D. Which part of cervical length is predictive of preterm birth in women with cerclage? J Matern Fetal Neonatal Med 2022; 35:10647-10652. [PMID: 36450362 DOI: 10.1080/14767058.2022.2152669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To evaluate the predictive value of transvaginal ultrasonography measures: total cervical length (TCL), length to internal OS (LIO) and external OS (LEO) from the cerclage following cerclage placement, for spontaneous preterm birth (PTB). METHODS A retrospective cohort at a single tertiary care center (2010-2020). Women with McDonald cerclage were evaluated during the 2nd and 3rd trimesters for cervical measurements: TCL, LIO, LEO. The primary outcome was PTB < 37 weeks. Demographic data, obstetric history, delivery information and serial cervical length measurements were collected. Subgroup analyses were performed to evaluate cervical length parameters (as described) and PTB rates prior to 34, 32 and 28 weeks of gestation. RESULTS Of 66 women enrolled, 36.4% (n = 24) had PTB. There were no differences in the obstetrical history and demographic information (p > .05) nor indication for cerclage (p = .369). Cervical length measurements at 20-24 weeks demonstrated a shorter TCL & LIO (22.69 vs. 33.86 mm, p = .001; 9.25 vs. 15.9 mm, p = .0042; respectively) in the preterm group. The LEO was similar in both groups. This pattern was also shown in a subgroup analysis (PTB < 34, 32 and 28 weeks). CONCLUSION Cervical length from internal OS to cerclage and total cervical length have a predictive value for PTB in women with a cervical cerclage, regardless of the indication for cerclage/previous pregnancy outcomes. Our data emphasize the importance of follow-up cervical length measurements of women with a cervical cerclage, and especially cervical length from internal OS to cerclage as those women may need additional care.
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Affiliation(s)
- Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Matan Attia
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Naama Farago
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Roy Lauterbach
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Boelig RC, Schoen CN, Frey H, Gimovsky AC, Springel E, Backley S, Berghella V. Vaginal progesterone vs intramuscular 17-hydroxyprogesterone caproate for prevention of recurrent preterm birth: a randomized controlled trial. Am J Obstet Gynecol 2022; 226:722.e1-722.e12. [PMID: 35189093 DOI: 10.1016/j.ajog.2022.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preterm birth is the leading cause of neonatal morbidity and mortality, and previous preterm birth is one of the strongest risk factors for preterm birth. National and international obstetrical societies have different recommendations regarding progesterone formulation for the prevention of recurrent preterm birth. OBJECTIVE This study aimed to determine whether vaginal progesterone is superior to 17-hydroxyprogesterone caproate in the prevention of recurrent preterm birth in patients with singleton pregnancies who had a previous spontaneous preterm birth. STUDY DESIGN This was an open-label multicenter pragmatic randomized controlled trial at 5 US centers of patients with singleton pregnancies at <24 weeks of gestation who had a previous spontaneous preterm birth randomized 1:1 to either 200 mg vaginal progesterone suppository nightly or 250 mg intramuscular 17-hydroxyprogesterone caproate weekly from 16 to 36 weeks of gestation. Based on the estimated recurrent preterm birth rate of 36% with 17-hydroxyprogesterone caproate, 95 participants were needed in each arm to detect a 50% reduction in preterm birth rate with vaginal progesterone, with 80% power and 2-sided alpha of 0.05. The primary outcome was preterm birth at <37 weeks of gestation. Prespecified secondary outcomes included preterm birth at <34 and <28 weeks of gestation, mean gestational age at delivery, neonatal morbidity and mortality, and measures of adherence. Analysis was by intention to treat. The chi-square test and Student t test were used as appropriate. P<.05 was considered significant. RESULTS Overall, 205 participants were randomized; 94 participants in the vaginal progesterone group and 94 participants in 17-hydroxyprogesterone caproate group were included. Although gestational age at enrollment was similar, those assigned to vaginal progesterone initiated therapy earlier (16.9±1.4 vs 17.8±2.5 weeks; P=.001). Overall continuation of assigned formulation until delivery was similar (73% vs 69%; P=.61). There was no significant difference in preterm birth at <37 (31% vs 38%; P=.28; relative risk, 0.81 [95% confidence interval, 0.54-1.20]), <34 (9.6% vs 14.9%; P=.26; relative risk, 0.64 [95% confidence interval, 0.29-1.41]), or <28 (1.1% vs 4.3%; P=.37; relative risk, 0.25 [95% confidence interval, 0.03-2.20]) weeks of gestation. Participants in the vaginal progesterone group had a later mean gestational age at delivery than participants in the 17-hydroxyprogesterone caproate group (37.36±2.72 vs 36.34±4.10 weeks; mean difference, 1.02 [95% confidence interval, 0.01-2.01]; P=.047). CONCLUSION Vaginal progesterone did not reduce the risk of recurrent preterm birth by 50% compared with 17-OHPC; however, vaginal progesterone may lead to increased latency to delivery. This trial was underpowered to detect a smaller, but still clinically significant, difference in the efficacy of preterm birth prevention. Patient factors that impact adherence and ability to obtain medication in a timely fashion should be included in counseling on progesterone selection.
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Corina N Schoen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UMass Chan Medical School-Baystate Health, Worcester, MA
| | - Heather Frey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Alexis C Gimovsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Edward Springel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA
| | - Sami Backley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UMass Chan Medical School-Baystate Health, Worcester, MA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Boelig RC, Roman A, Berghella V. Reply: Screening for preterm birth prevention: more than just 1 number? Am J Obstet Gynecol 2022; 226:450-451. [PMID: 34666053 DOI: 10.1016/j.ajog.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut St., 1st Floor, Philadelphia, PA 19107.
| | - Amanda Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut St., 1st Floor, Philadelphia, PA 19107
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut St., 1st Floor, Philadelphia, PA 19107
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Should singleton gestations without prior preterm birth receive an ultrasound-indicated cerclage? Tempting, but we must wait for more level 1 data. Am J Obstet Gynecol MFM 2021; 3:100431. [PMID: 34419385 DOI: 10.1016/j.ajogmf.2021.100431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
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Boelig RC, Kripalu V, Chen SL, Cruz Y, Roman A, Berghella V. Utility of follow-up cervical length screening in low-risk women with a cervical length of 26 to 29 mm. Am J Obstet Gynecol 2021; 225:179.e1-179.e6. [PMID: 33652056 PMCID: PMC8328875 DOI: 10.1016/j.ajog.2021.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/04/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In women with a previous preterm birth, a protocol for serial cervical length screening has been studied and recommended for the identification and treatment of a short cervix. Cervical length screening along with vaginal progesterone has been suggested for low-risk women with singleton pregnancies to treat a short cervix and reduce preterm birth. However, specific protocols for single vs serial ultrasound measuring cervical length in this population are not established. Cost-effectiveness of universal cervical length screening depends on the cost of screening; follow-up of borderline measurements can contribute to increased costs with uncertain benefit. OBJECTIVE This study aimed to determine the utility of follow-up cervical length screening in otherwise low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm through the assessment of the rate of short cervix (≤25 mm) on follow-up ultrasound and subsequent delivery outcomes. STUDY DESIGN This was a 2-year retrospective cohort study at a single urban institution of women with singleton pregnancies with no previous spontaneous preterm birth and an initial transvaginal ultrasound cervical length measurement of 26 to 29 mm identified during universal cervical length screening at time of anatomy ultrasound (18 0/7 to 22 6/7 weeks' gestation). The primary outcome was the rate of short cervix (defined as ≤25 mm on transvaginal ultrasound) on follow-up ultrasound at <24 weeks' gestation. Secondary outcomes included the rate of spontaneous preterm birth (<37 and <34 weeks' gestation). RESULTS During the study period, there were 2801 women with singleton pregnancies at 18 0/7 to 22 6/7 weeks' gestation with transvaginal ultrasound cervical length screening at time of anatomy scan. Among those women, 201 had a cervical length of 26 of 29 mm, and 184 (7%) had no previous spontaneous preterm birth and were included in the study. Furthermore, 144 women (78%) had a follow-up cervical length completed before 24 weeks' gestation. The mean follow-up interval was 1.5±0.6 weeks. Overall, the percentage of short cervix (≤25 mm) on follow-up was 15% (n=21). Baseline characteristics were similar, but the initial cervical length measurement was shorter in women who subsequently developed a short cervix (26.7±0.8 vs 27.8±1.0; P<.01). Delivery outcomes were available for 126 patients. The rate of spontaneous preterm birth at <37 weeks' gestation in women with an initial cervical length 26 to 29 mm and subsequent short cervix was significantly higher than the rate of spontaneous preterm birth in a historical cohort of low risk women with an initial cervical length >25 mm (16% vs 3%; P=.03). The rate of spontaneous preterm birth at <34 weeks' gestation in women with a subsequent short cervix was 11% (2 of 19). CONCLUSION Here, approximately 15% of low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm will experience cervical shortening of ≤25 mm before 24 weeks' gestation. Compared to women with singleton pregnancies without a history of preterm birth, the rate of spontaneous preterm birth (16%) in women with an initial cervical length of 26 to 29 mm and a subsequent cervical shortening of ≤25 mm is significantly higher. A total of 111 follow-up ultrasounds measuring cervical length would be required to prevent 1 early preterm birth at <34 weeks' gestation.
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Varsha Kripalu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Sarah L Chen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Yuri Cruz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Amanda Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Gudicha DW, Romero R, Kabiri D, Hernandez-Andrade E, Pacora P, Erez O, Kusanovic JP, Jung E, Paredes C, Berry SM, Yeo L, Hassan SS, Hsu CD, Tarca AL. Personalized assessment of cervical length improves prediction of spontaneous preterm birth: a standard and a percentile calculator. Am J Obstet Gynecol 2021; 224:288.e1-288.e17. [PMID: 32918893 PMCID: PMC7914140 DOI: 10.1016/j.ajog.2020.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A sonographic short cervix (length <25 mm during midgestation) is the most powerful predictor of preterm birth. Current clinical practice assumes that the same cervical length cutoff value should apply to all women when screening for spontaneous preterm birth, yet this approach may be suboptimal. OBJECTIVE This study aimed to (1) create a customized cervical length standard that considers relevant maternal characteristics and gestational age at sonographic examination and (2) assess whether the customization of cervical length evaluation improves the prediction of spontaneous preterm birth. STUDY DESIGN This retrospective analysis comprises a cohort of 7826 pregnant women enrolled in a longitudinal protocol between January 2006 and April 2017 at the Detroit Medical Center. Study participants met the following inclusion criteria: singleton pregnancy, ≥1 transvaginal sonographic measurements of the cervix, delivery after 20 weeks of gestation, and available relevant demographics and obstetrical history information. Data from women without a history of preterm birth or cervical surgery who delivered at term without progesterone treatment (N=5188) were used to create a customized standard of cervical length. The prediction of the primary outcome, spontaneous preterm birth at <37 weeks of gestation, was assessed in a subset of pregnancies (N=7336) that excluded cases with induced labor before 37 weeks of gestation. Area under the receiver operating characteristic curve and sensitivity at a fixed false-positive rate were calculated for screening at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation in asymptomatic patients. Survival analysis was used to determine which method is better at predicting imminent delivery among symptomatic women. RESULTS The median cervical length remained fundamentally unchanged until 20 weeks of gestation and subsequently decreased nonlinearly with advancing gestational age among women who delivered at term. The effects of parity and maternal weight and height on the cervical length were dependent on the gestational age at ultrasound examination (interaction, P<.05 for all). Parous women had a longer cervix than nulliparous women, and the difference increased with advancing gestation after adjusting for maternal weight and height. Similarly, maternal weight was nonlinearly associated with a longer cervix, and the effect was greater later in gestation. The sensitivity at a 10% false-positive rate for prediction of spontaneous preterm birth at <37 weeks of gestation by a short cervix ranged from 29% to 40% throughout pregnancy, yet it increased to 50%, 50%, 53%, and 54% at 20 to 23 6/7, 24 to 27 6/7, 28 to 31 6/7, and 32 to 35 6/7 weeks of gestation, respectively, for a low, customized percentile (McNemar test, P<.001 for all). When a cervical length <25 mm was compared to the customized screening at 20 to 23 6/7 weeks of gestation by using a customized percentile cutoff value that ensured the same negative likelihood ratio for both screening methods, the customized approach had a significantly higher (about double) positive likelihood ratio in predicting spontaneous preterm birth at <33, <34, <35, <36, and <37 weeks of gestation. Among symptomatic women, the difference in survival between women with a customized cervical length percentile of ≥10th and those with a customized cervical length percentile of <10th was greater than the difference in survival between women with a cervical length ≥25 mm and those with a cervical length <25 mm. CONCLUSION Compared to the use of a cervical length <25 mm, a customized cervical length assessment (1) identifies more women at risk of spontaneous preterm birth and (2) improves the distinction between patients at risk for impending preterm birth in those who have an episode of preterm labor.
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Affiliation(s)
- Dereje W Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Florida International University, Miami, FL
| | - Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Maternity Department "D," Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Beer-Sheva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Center for Research and Innovation in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sótero del Río Hospital, Santiago, Chile; Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Carmen Paredes
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Stanley M Berry
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Sonia S Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Office of Women's Health, Integrative Biosciences Center, Wayne State University, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, and Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI.
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