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Universal cervical length screening–saving babies lives
Universal second-trimester transvaginal ultrasound cervical length screening of both singleton and twin gestations should be seriously considered by obstetric practitioners to successfully decrease the grave burden of spontaneous preterm birth
Author(s)
Vincenzo Berghella, MD
Rupsa C. Boelig, MD

Images: Courtesy of Perinatal Quality Foundation
Transvaginal ultrasound image of normal cervical length (A) and short cervical length (B).

Transvaginal ultrasound (TVU) cervical length (CL) screening for prediction and prevention of spontaneous preterm birth (SPTB) is among the most transformative clinical changes in obstetrics in the last decades. TVU CL screening should now be offered to all pregnant women: hence the appellative ‘universal CL screening.’

TVU CL screening is an excellent screening test for several reasons. It screens for SPTB, which is a clinically important, well-defined disease whose prevalence and natural history is known, and has an early recognizable asymptomatic phase in CL shortening detected by TVU. TVU CL screening is a well-described technique, safe and acceptable, with a reasonable cutoff (25 mm) now identified for all populations, and results are reproducible and accurate. There are hundreds of studies proving these facts. In the last 10 years, TVU measurement of CL as a screening test has been accepted1,2: it identifies women at risk for SPTB, and an early intervention (progesterone or cerclage depending on the clinical situation) is effective in preventing SPTB. Screening and treatment of short cervix is cost-effective and readily available as an early intervention (progesterone or cerclage depending on the clinical situation), is effective in preventing the outcome (SPTB), treating abnormal results is cost-effective, and facilities for screening are available and treatments are readily available.3–5 It is also important to emphasize that CL screening for prevention of SPTB should be done by TVU, and not by transabdominal ultrasound.6It is best to review TVU CL screening by populations: singletons without prior SPTB, singletons with prior SPTB, and twins (Table).

Related Article:
Can transabdominal ultrasound exclude short cervix?

 

Singletons without prior SPTB

Women with no previous SPTB who are carrying a singleton pregnancy is the population in which TVU CL could have the greatest impact on decreasing SPTB, for several reasons:

  1. Up to 60% to 90% of SPTB occur in this population.
  2. More than 90% of these women have risk factors for SPTB.7,8
  3. Vaginal progesterone has been associated with a significant 39% decrease in PTB at <33 weeks of gestation and a significant 38% decrease in perinatal morbidity and mortality in a meta-analysis of randomized controlled trials (RCTs) including 606 women without prior PTB.9,10
  4. Cost-effectiveness studies have shown that TVU CL screening in this specific population prevents thousands of preterm births, saves or improves from death or major morbidity 350 babies’ lives annually, and saves approximately $320,000 per year in the US alone.3 These numbers may be even higher now as the TVU CL cutoff for offering vaginal progesterone has moved in many centers from ≤20 mm to ≤25 mm, including more women (from about 0.8% to about 2% to 3%, respectively11) who benefit from screening.
  5. Real-world implementation studies have indeed shown significant decreases in SPTB when a policy of universal TVU CL screening in this specific population is implemented.12,13

Universal TVU CL screening recently called into question

In a recent article published in the Journal of the American Medical Association,14 TVU CL screening in this population, in particular for nulliparous women, has come under interrogation. The authors found only an 8% sensitivity of TVU CL screening for SPTB using a cutoff of ≤25 mm at 16 0/7 to 22 6/7 weeks of gestation in 9,410 nulliparous women. This result is different compared with other previous cohort studies in this area, however, and is likely related to a number of issues in the methodology.

First, TVU CL screening was done in many women at too early a gestational age. The earlier the CL screening, the lower the sensitivity of the procedure. Data at 16 and 17 weeks of gestation should have been excluded, as almost all RCTs and other studies on universal TVU CL screening in this population recommended doing screening at about 18 0/7 to 23 6/7 weeks.

Second, women with TVU CL <15 mm received vaginal progesterone. This would decrease the incidence of PTB and, therefore, sensitivity.

Third, outcomes data were not available for 469 women and, compared with women analyzed, these women were at higher risk for SPTB as they were more likely to be aged 21 years or younger, black, with less than a high school education, and single, all significant risk factors for SPTB. (Not all risk factors for SPTB were reported in this study.)

Fourth, pregnancy losses before 20 weeks were excluded, and these could have been early SPTB; therefore, the sensitivity could have been decreased if women with this outcome were excluded.

Fifth, prior studies have shown that TVU CL screening in singletons without prior SPTB has a sensitivity of about 30% to 40%.15,16 In nulliparas, the sensitivity of TVU CL ≤20 mm had been reported previously to be 20%.16 Additional data from 2012–2014 at our institution demonstrate that the incidence of CL ≤25 mm is about 2.8% in nulliparous women, with a sensitivity of 19.5% for SPTB <37 weeks. These numbers show again that 8% sensitivity was low in the JAMA study14 due the shortcomings we just highlighted. Furthermore, the reported sensitivity of TVU CL ≤25 mm for PTB <32 weeks was 24% in Esplin and colleagues’ study,14 while 60% in our data. Given that early preterm births are the most significant source of neonatal morbidity and mortality, women with a singleton gestation and no prior SPTB but with a short TVU CL are perhaps the most important subgroup to identify.

Sixth, a low sensitivity in and of itself is not reflective of a poor screening test. We have known for a long time that SPTB has many etiologies. No one screening test, and no one intervention, would independently prevent all SPTBs. In a population that accounts for more than half of PTBs and for whom no other screening test has been found to be effective, much less cost effective, it is important not to cast aside the dramatic potential clinical benefit to TVU CL screening.

 

Related Article:
A stepwise approach to cervical cerclage

 

 

 

Singletons with a prior SPTB

This is the first population in which TVU CL screening was first proven beneficial for prevention of SPTB. These women all should receive progesterone starting at 16 weeks because of the prior SPTB. In these women, TVU CL screening should be initiated at 16 weeks, and repeated every 2 weeks (weekly if TVU CL is found to be 25 mm to 29 mm) until 23 6/7 weeks. If the TVU CL is identified to be <25 mm before 24 weeks, cerclage should be recommended.1,2,17

Twins

Twins are the most recent population in which an intervention based on TVU CL screening has been shown to be beneficial. Vaginal progesterone has been associated with a significant decrease in SPTB as well as in some neonatal outcomes in twin gestations found to have a TVU CL <25 mm in the midtrimester in a meta-analysis of RCTs.18 Based on these results, we at our institution recently have started offering TVU CL screening at the time of the anatomy scan (about 20 weeks) to twin gestations.

 

Related Article:
Which perioperative strategies for transvaginal cervical cerclage are backed by data?

 

Bottom line

In summary, universal second trimester TVU CL screening of both singletons and twin gestations should be considered seriously by obstetric practitioners to successfully decrease the grave burden of SPTB.

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

References
  1. Berghella V. Progesterone and preterm birth prevention: Translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376-386.  
  2. Committee on Practice Bulletins--Obstetrics, The American College of Obstetricians and Gynecologists. Practice Bulletin No. 130: Prediction and prevention of preterm birth. Obstet Gynecol. 2012;120(4):964-973.  
  3. Werner EF, Hamel MS, Orzechowski K, Berghella V, Thung SF. Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update. Am J Obstet Gynecol. 2015;213(4):554.e1-e6.  
  4. 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(1):100.e1-e7.  
  5. McIntosh J, Feltovich H, Berghella V, Manuck T; Society for Maternal-Fetal medicine. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016;215(3):B2-B7.  
  6. Khalifeh A, Quist-Nelson J. Current implementation of universal cervical length screening for preterm birth prevention in the United States. Obstet Gynecol. 2016;127(suppl 1):7S.
  7. Mella MT, Mackeen AD, Gache D, Baxter JK, Berghella V. The utility of screening for historical risk factors for preterm birth in women with known second trimester cervical length. J Matern Fetal Neonatal Med. 2013;26(7):710-715.  
  8. Saccone G, Perriera L, Berghella V. Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016;214(5):572-591.  
  9. Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: A systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol. 2012;206(2):124.e1-e19.  
  10. Romero R, Nicolaides KH, Conde-Agudelo A, et al. Vaginal progesterone decreases preterm birth ≤34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. Ultrasound Obstet Gynecol. 2016;48(3):308-317.  
  11. Orzechoski KM, Boelig RC, Baxter JK, Berghella V. A universal transvaginal cervical length screening program for preterm birth prevention. Obstet Gynecol. 2014;124(3):520-525.
  12. Son M, Grobman WA, Ayala NK, Miller ES. A universal mid-trimester transvaginal cervical length screening program and its associated reduced preterm birth rate. Am J Obstet Gynecol. 2016;214(3):365.e1-e5.  
  13. Temming LA, Durst JK, Tuuli MG, et al. Universal cervical length screening: implementation and outcomes. Am J Obstet Gynecol. 2016;214(4):523.e1-e8.  
  14. Esplin MS, Elovitz MA, Iams JD, et al; njMoM2b Network. Predictive accuracy of serial ttransvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. JAMA. 2017;317(10):1047-1056.  
  15. Iams JD, Goldenberg RL, Meis PJ, et al. 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(9):567-572.
  16. Orzechowski KM, Boelig R, Nicholas SS, Baxter J, Berghella V. Is universal cervical length screening indicated in women with prior term birth? Am J Obstet Gynecol. 2015;212(2):234.e1-e5.  
  17. Preterm labour and birth. National Institute for Health and Care Excellence website. https://www.nice.org.uk/guidance/ng25?unlid=9291036072016213201257. Published November 2015. Accessed May 18, 2017.  
  18. Romero R, Conde-Agudelo A, El-Refaie W, et al. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. Ultrasound Obstet Gynecol. 2017;49(3):303-314.
Author and Disclosure Information

Vincenzo Berghella, MD
Dr. Berghella is Director, Division of Maternal-Fetal Medicine, and Professor, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania


Rupsa C. Boelig, MD
Dr. Boelig is Fellow, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University

Issue
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MDedge ObGyn
OBG Management
Topics
Obstetrics
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7-9
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Expert Commentary
Author(s)
Vincenzo Berghella, MD
Rupsa C. Boelig, MD
Author(s)
Vincenzo Berghella, MD
Rupsa C. Boelig, MD
Author and Disclosure Information

Vincenzo Berghella, MD
Dr. Berghella is Director, Division of Maternal-Fetal Medicine, and Professor, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania


Rupsa C. Boelig, MD
Dr. Boelig is Fellow, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University

Author and Disclosure Information

Vincenzo Berghella, MD
Dr. Berghella is Director, Division of Maternal-Fetal Medicine, and Professor, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania


Rupsa C. Boelig, MD
Dr. Boelig is Fellow, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University

Universal second-trimester transvaginal ultrasound cervical length screening of both singleton and twin gestations should be seriously considered by obstetric practitioners to successfully decrease the grave burden of spontaneous preterm birth
Universal second-trimester transvaginal ultrasound cervical length screening of both singleton and twin gestations should be seriously considered by obstetric practitioners to successfully decrease the grave burden of spontaneous preterm birth

Images: Courtesy of Perinatal Quality Foundation
Transvaginal ultrasound image of normal cervical length (A) and short cervical length (B).

Transvaginal ultrasound (TVU) cervical length (CL) screening for prediction and prevention of spontaneous preterm birth (SPTB) is among the most transformative clinical changes in obstetrics in the last decades. TVU CL screening should now be offered to all pregnant women: hence the appellative ‘universal CL screening.’

TVU CL screening is an excellent screening test for several reasons. It screens for SPTB, which is a clinically important, well-defined disease whose prevalence and natural history is known, and has an early recognizable asymptomatic phase in CL shortening detected by TVU. TVU CL screening is a well-described technique, safe and acceptable, with a reasonable cutoff (25 mm) now identified for all populations, and results are reproducible and accurate. There are hundreds of studies proving these facts. In the last 10 years, TVU measurement of CL as a screening test has been accepted1,2: it identifies women at risk for SPTB, and an early intervention (progesterone or cerclage depending on the clinical situation) is effective in preventing SPTB. Screening and treatment of short cervix is cost-effective and readily available as an early intervention (progesterone or cerclage depending on the clinical situation), is effective in preventing the outcome (SPTB), treating abnormal results is cost-effective, and facilities for screening are available and treatments are readily available.3–5 It is also important to emphasize that CL screening for prevention of SPTB should be done by TVU, and not by transabdominal ultrasound.6It is best to review TVU CL screening by populations: singletons without prior SPTB, singletons with prior SPTB, and twins (Table).

Related Article:
Can transabdominal ultrasound exclude short cervix?

 

Singletons without prior SPTB

Women with no previous SPTB who are carrying a singleton pregnancy is the population in which TVU CL could have the greatest impact on decreasing SPTB, for several reasons:

  1. Up to 60% to 90% of SPTB occur in this population.
  2. More than 90% of these women have risk factors for SPTB.7,8
  3. Vaginal progesterone has been associated with a significant 39% decrease in PTB at <33 weeks of gestation and a significant 38% decrease in perinatal morbidity and mortality in a meta-analysis of randomized controlled trials (RCTs) including 606 women without prior PTB.9,10
  4. Cost-effectiveness studies have shown that TVU CL screening in this specific population prevents thousands of preterm births, saves or improves from death or major morbidity 350 babies’ lives annually, and saves approximately $320,000 per year in the US alone.3 These numbers may be even higher now as the TVU CL cutoff for offering vaginal progesterone has moved in many centers from ≤20 mm to ≤25 mm, including more women (from about 0.8% to about 2% to 3%, respectively11) who benefit from screening.
  5. Real-world implementation studies have indeed shown significant decreases in SPTB when a policy of universal TVU CL screening in this specific population is implemented.12,13

Universal TVU CL screening recently called into question

In a recent article published in the Journal of the American Medical Association,14 TVU CL screening in this population, in particular for nulliparous women, has come under interrogation. The authors found only an 8% sensitivity of TVU CL screening for SPTB using a cutoff of ≤25 mm at 16 0/7 to 22 6/7 weeks of gestation in 9,410 nulliparous women. This result is different compared with other previous cohort studies in this area, however, and is likely related to a number of issues in the methodology.

First, TVU CL screening was done in many women at too early a gestational age. The earlier the CL screening, the lower the sensitivity of the procedure. Data at 16 and 17 weeks of gestation should have been excluded, as almost all RCTs and other studies on universal TVU CL screening in this population recommended doing screening at about 18 0/7 to 23 6/7 weeks.

Second, women with TVU CL <15 mm received vaginal progesterone. This would decrease the incidence of PTB and, therefore, sensitivity.

Third, outcomes data were not available for 469 women and, compared with women analyzed, these women were at higher risk for SPTB as they were more likely to be aged 21 years or younger, black, with less than a high school education, and single, all significant risk factors for SPTB. (Not all risk factors for SPTB were reported in this study.)

Fourth, pregnancy losses before 20 weeks were excluded, and these could have been early SPTB; therefore, the sensitivity could have been decreased if women with this outcome were excluded.

Fifth, prior studies have shown that TVU CL screening in singletons without prior SPTB has a sensitivity of about 30% to 40%.15,16 In nulliparas, the sensitivity of TVU CL ≤20 mm had been reported previously to be 20%.16 Additional data from 2012–2014 at our institution demonstrate that the incidence of CL ≤25 mm is about 2.8% in nulliparous women, with a sensitivity of 19.5% for SPTB <37 weeks. These numbers show again that 8% sensitivity was low in the JAMA study14 due the shortcomings we just highlighted. Furthermore, the reported sensitivity of TVU CL ≤25 mm for PTB <32 weeks was 24% in Esplin and colleagues’ study,14 while 60% in our data. Given that early preterm births are the most significant source of neonatal morbidity and mortality, women with a singleton gestation and no prior SPTB but with a short TVU CL are perhaps the most important subgroup to identify.

Sixth, a low sensitivity in and of itself is not reflective of a poor screening test. We have known for a long time that SPTB has many etiologies. No one screening test, and no one intervention, would independently prevent all SPTBs. In a population that accounts for more than half of PTBs and for whom no other screening test has been found to be effective, much less cost effective, it is important not to cast aside the dramatic potential clinical benefit to TVU CL screening.

 

Related Article:
A stepwise approach to cervical cerclage

 

 

 

Singletons with a prior SPTB

This is the first population in which TVU CL screening was first proven beneficial for prevention of SPTB. These women all should receive progesterone starting at 16 weeks because of the prior SPTB. In these women, TVU CL screening should be initiated at 16 weeks, and repeated every 2 weeks (weekly if TVU CL is found to be 25 mm to 29 mm) until 23 6/7 weeks. If the TVU CL is identified to be <25 mm before 24 weeks, cerclage should be recommended.1,2,17

Twins

Twins are the most recent population in which an intervention based on TVU CL screening has been shown to be beneficial. Vaginal progesterone has been associated with a significant decrease in SPTB as well as in some neonatal outcomes in twin gestations found to have a TVU CL <25 mm in the midtrimester in a meta-analysis of RCTs.18 Based on these results, we at our institution recently have started offering TVU CL screening at the time of the anatomy scan (about 20 weeks) to twin gestations.

 

Related Article:
Which perioperative strategies for transvaginal cervical cerclage are backed by data?

 

Bottom line

In summary, universal second trimester TVU CL screening of both singletons and twin gestations should be considered seriously by obstetric practitioners to successfully decrease the grave burden of SPTB.

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Images: Courtesy of Perinatal Quality Foundation
Transvaginal ultrasound image of normal cervical length (A) and short cervical length (B).

Transvaginal ultrasound (TVU) cervical length (CL) screening for prediction and prevention of spontaneous preterm birth (SPTB) is among the most transformative clinical changes in obstetrics in the last decades. TVU CL screening should now be offered to all pregnant women: hence the appellative ‘universal CL screening.’

TVU CL screening is an excellent screening test for several reasons. It screens for SPTB, which is a clinically important, well-defined disease whose prevalence and natural history is known, and has an early recognizable asymptomatic phase in CL shortening detected by TVU. TVU CL screening is a well-described technique, safe and acceptable, with a reasonable cutoff (25 mm) now identified for all populations, and results are reproducible and accurate. There are hundreds of studies proving these facts. In the last 10 years, TVU measurement of CL as a screening test has been accepted1,2: it identifies women at risk for SPTB, and an early intervention (progesterone or cerclage depending on the clinical situation) is effective in preventing SPTB. Screening and treatment of short cervix is cost-effective and readily available as an early intervention (progesterone or cerclage depending on the clinical situation), is effective in preventing the outcome (SPTB), treating abnormal results is cost-effective, and facilities for screening are available and treatments are readily available.3–5 It is also important to emphasize that CL screening for prevention of SPTB should be done by TVU, and not by transabdominal ultrasound.6It is best to review TVU CL screening by populations: singletons without prior SPTB, singletons with prior SPTB, and twins (Table).

Related Article:
Can transabdominal ultrasound exclude short cervix?

 

Singletons without prior SPTB

Women with no previous SPTB who are carrying a singleton pregnancy is the population in which TVU CL could have the greatest impact on decreasing SPTB, for several reasons:

  1. Up to 60% to 90% of SPTB occur in this population.
  2. More than 90% of these women have risk factors for SPTB.7,8
  3. Vaginal progesterone has been associated with a significant 39% decrease in PTB at <33 weeks of gestation and a significant 38% decrease in perinatal morbidity and mortality in a meta-analysis of randomized controlled trials (RCTs) including 606 women without prior PTB.9,10
  4. Cost-effectiveness studies have shown that TVU CL screening in this specific population prevents thousands of preterm births, saves or improves from death or major morbidity 350 babies’ lives annually, and saves approximately $320,000 per year in the US alone.3 These numbers may be even higher now as the TVU CL cutoff for offering vaginal progesterone has moved in many centers from ≤20 mm to ≤25 mm, including more women (from about 0.8% to about 2% to 3%, respectively11) who benefit from screening.
  5. Real-world implementation studies have indeed shown significant decreases in SPTB when a policy of universal TVU CL screening in this specific population is implemented.12,13

Universal TVU CL screening recently called into question

In a recent article published in the Journal of the American Medical Association,14 TVU CL screening in this population, in particular for nulliparous women, has come under interrogation. The authors found only an 8% sensitivity of TVU CL screening for SPTB using a cutoff of ≤25 mm at 16 0/7 to 22 6/7 weeks of gestation in 9,410 nulliparous women. This result is different compared with other previous cohort studies in this area, however, and is likely related to a number of issues in the methodology.

First, TVU CL screening was done in many women at too early a gestational age. The earlier the CL screening, the lower the sensitivity of the procedure. Data at 16 and 17 weeks of gestation should have been excluded, as almost all RCTs and other studies on universal TVU CL screening in this population recommended doing screening at about 18 0/7 to 23 6/7 weeks.

Second, women with TVU CL <15 mm received vaginal progesterone. This would decrease the incidence of PTB and, therefore, sensitivity.

Third, outcomes data were not available for 469 women and, compared with women analyzed, these women were at higher risk for SPTB as they were more likely to be aged 21 years or younger, black, with less than a high school education, and single, all significant risk factors for SPTB. (Not all risk factors for SPTB were reported in this study.)

Fourth, pregnancy losses before 20 weeks were excluded, and these could have been early SPTB; therefore, the sensitivity could have been decreased if women with this outcome were excluded.

Fifth, prior studies have shown that TVU CL screening in singletons without prior SPTB has a sensitivity of about 30% to 40%.15,16 In nulliparas, the sensitivity of TVU CL ≤20 mm had been reported previously to be 20%.16 Additional data from 2012–2014 at our institution demonstrate that the incidence of CL ≤25 mm is about 2.8% in nulliparous women, with a sensitivity of 19.5% for SPTB <37 weeks. These numbers show again that 8% sensitivity was low in the JAMA study14 due the shortcomings we just highlighted. Furthermore, the reported sensitivity of TVU CL ≤25 mm for PTB <32 weeks was 24% in Esplin and colleagues’ study,14 while 60% in our data. Given that early preterm births are the most significant source of neonatal morbidity and mortality, women with a singleton gestation and no prior SPTB but with a short TVU CL are perhaps the most important subgroup to identify.

Sixth, a low sensitivity in and of itself is not reflective of a poor screening test. We have known for a long time that SPTB has many etiologies. No one screening test, and no one intervention, would independently prevent all SPTBs. In a population that accounts for more than half of PTBs and for whom no other screening test has been found to be effective, much less cost effective, it is important not to cast aside the dramatic potential clinical benefit to TVU CL screening.

 

Related Article:
A stepwise approach to cervical cerclage

 

 

 

Singletons with a prior SPTB

This is the first population in which TVU CL screening was first proven beneficial for prevention of SPTB. These women all should receive progesterone starting at 16 weeks because of the prior SPTB. In these women, TVU CL screening should be initiated at 16 weeks, and repeated every 2 weeks (weekly if TVU CL is found to be 25 mm to 29 mm) until 23 6/7 weeks. If the TVU CL is identified to be <25 mm before 24 weeks, cerclage should be recommended.1,2,17

Twins

Twins are the most recent population in which an intervention based on TVU CL screening has been shown to be beneficial. Vaginal progesterone has been associated with a significant decrease in SPTB as well as in some neonatal outcomes in twin gestations found to have a TVU CL <25 mm in the midtrimester in a meta-analysis of RCTs.18 Based on these results, we at our institution recently have started offering TVU CL screening at the time of the anatomy scan (about 20 weeks) to twin gestations.

 

Related Article:
Which perioperative strategies for transvaginal cervical cerclage are backed by data?

 

Bottom line

In summary, universal second trimester TVU CL screening of both singletons and twin gestations should be considered seriously by obstetric practitioners to successfully decrease the grave burden of SPTB.

 

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

References
  1. Berghella V. Progesterone and preterm birth prevention: Translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376-386.  
  2. Committee on Practice Bulletins--Obstetrics, The American College of Obstetricians and Gynecologists. Practice Bulletin No. 130: Prediction and prevention of preterm birth. Obstet Gynecol. 2012;120(4):964-973.  
  3. Werner EF, Hamel MS, Orzechowski K, Berghella V, Thung SF. Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update. Am J Obstet Gynecol. 2015;213(4):554.e1-e6.  
  4. 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(1):100.e1-e7.  
  5. McIntosh J, Feltovich H, Berghella V, Manuck T; Society for Maternal-Fetal medicine. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016;215(3):B2-B7.  
  6. Khalifeh A, Quist-Nelson J. Current implementation of universal cervical length screening for preterm birth prevention in the United States. Obstet Gynecol. 2016;127(suppl 1):7S.
  7. Mella MT, Mackeen AD, Gache D, Baxter JK, Berghella V. The utility of screening for historical risk factors for preterm birth in women with known second trimester cervical length. J Matern Fetal Neonatal Med. 2013;26(7):710-715.  
  8. Saccone G, Perriera L, Berghella V. Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016;214(5):572-591.  
  9. Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: A systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol. 2012;206(2):124.e1-e19.  
  10. Romero R, Nicolaides KH, Conde-Agudelo A, et al. Vaginal progesterone decreases preterm birth ≤34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. Ultrasound Obstet Gynecol. 2016;48(3):308-317.  
  11. Orzechoski KM, Boelig RC, Baxter JK, Berghella V. A universal transvaginal cervical length screening program for preterm birth prevention. Obstet Gynecol. 2014;124(3):520-525.
  12. Son M, Grobman WA, Ayala NK, Miller ES. A universal mid-trimester transvaginal cervical length screening program and its associated reduced preterm birth rate. Am J Obstet Gynecol. 2016;214(3):365.e1-e5.  
  13. Temming LA, Durst JK, Tuuli MG, et al. Universal cervical length screening: implementation and outcomes. Am J Obstet Gynecol. 2016;214(4):523.e1-e8.  
  14. Esplin MS, Elovitz MA, Iams JD, et al; njMoM2b Network. Predictive accuracy of serial ttransvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. JAMA. 2017;317(10):1047-1056.  
  15. Iams JD, Goldenberg RL, Meis PJ, et al. 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(9):567-572.
  16. Orzechowski KM, Boelig R, Nicholas SS, Baxter J, Berghella V. Is universal cervical length screening indicated in women with prior term birth? Am J Obstet Gynecol. 2015;212(2):234.e1-e5.  
  17. Preterm labour and birth. National Institute for Health and Care Excellence website. https://www.nice.org.uk/guidance/ng25?unlid=9291036072016213201257. Published November 2015. Accessed May 18, 2017.  
  18. Romero R, Conde-Agudelo A, El-Refaie W, et al. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. Ultrasound Obstet Gynecol. 2017;49(3):303-314.
References
  1. Berghella V. Progesterone and preterm birth prevention: Translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376-386.  
  2. Committee on Practice Bulletins--Obstetrics, The American College of Obstetricians and Gynecologists. Practice Bulletin No. 130: Prediction and prevention of preterm birth. Obstet Gynecol. 2012;120(4):964-973.  
  3. Werner EF, Hamel MS, Orzechowski K, Berghella V, Thung SF. Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update. Am J Obstet Gynecol. 2015;213(4):554.e1-e6.  
  4. 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(1):100.e1-e7.  
  5. McIntosh J, Feltovich H, Berghella V, Manuck T; Society for Maternal-Fetal medicine. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016;215(3):B2-B7.  
  6. Khalifeh A, Quist-Nelson J. Current implementation of universal cervical length screening for preterm birth prevention in the United States. Obstet Gynecol. 2016;127(suppl 1):7S.
  7. Mella MT, Mackeen AD, Gache D, Baxter JK, Berghella V. The utility of screening for historical risk factors for preterm birth in women with known second trimester cervical length. J Matern Fetal Neonatal Med. 2013;26(7):710-715.  
  8. Saccone G, Perriera L, Berghella V. Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016;214(5):572-591.  
  9. Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: A systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol. 2012;206(2):124.e1-e19.  
  10. Romero R, Nicolaides KH, Conde-Agudelo A, et al. Vaginal progesterone decreases preterm birth ≤34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. Ultrasound Obstet Gynecol. 2016;48(3):308-317.  
  11. Orzechoski KM, Boelig RC, Baxter JK, Berghella V. A universal transvaginal cervical length screening program for preterm birth prevention. Obstet Gynecol. 2014;124(3):520-525.
  12. Son M, Grobman WA, Ayala NK, Miller ES. A universal mid-trimester transvaginal cervical length screening program and its associated reduced preterm birth rate. Am J Obstet Gynecol. 2016;214(3):365.e1-e5.  
  13. Temming LA, Durst JK, Tuuli MG, et al. Universal cervical length screening: implementation and outcomes. Am J Obstet Gynecol. 2016;214(4):523.e1-e8.  
  14. Esplin MS, Elovitz MA, Iams JD, et al; njMoM2b Network. Predictive accuracy of serial ttransvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. JAMA. 2017;317(10):1047-1056.  
  15. Iams JD, Goldenberg RL, Meis PJ, et al. 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(9):567-572.
  16. Orzechowski KM, Boelig R, Nicholas SS, Baxter J, Berghella V. Is universal cervical length screening indicated in women with prior term birth? Am J Obstet Gynecol. 2015;212(2):234.e1-e5.  
  17. Preterm labour and birth. National Institute for Health and Care Excellence website. https://www.nice.org.uk/guidance/ng25?unlid=9291036072016213201257. Published November 2015. Accessed May 18, 2017.  
  18. Romero R, Conde-Agudelo A, El-Refaie W, et al. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. Ultrasound Obstet Gynecol. 2017;49(3):303-314.
Issue
OBG Management - 29(6)
Issue
OBG Management - 29(6)
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7-9
Page Number
7-9
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MDedge ObGyn
OBG Management
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Universal cervical length screening–saving babies lives
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Universal cervical length screening–saving babies lives
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