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-off’s 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

22 (3): 305-22. Heath VC. Souka AP. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. Das A. there is no clear evidence that therapeutic intervention for those with a short cervix reduces the risk of preterm delivery.12. 334: 567-572. Cervical length at 23 weeks of gestation: relation to demographic characteristics and previous obstetric history. Cervical length at weeks of gestation: prediction of spontaneous preterm delivery.20mm appears to be appropriate. Whilst cervical length also has predictive value in twin pregnancies. Ultrasound Obstet Gynecol 1998. McNellis D. 12 (5): 304-11.e19. The length of the cervix and the risk of spontaneous premature delivery. Cam C. 2 RANZCOGCollege Statement: C-Obs 27 . Cervical length and obstetric history predictspontaneous preterm birth: development and validation of a model to provideindividualized risk assessment. N Engl J Med 1996. Cetingoz E. To M. however. Diaz-Garcia C. Honest H.9 Further research in this area would be of value. be some benefit in recognising multiple pregnancies at risk of preterm delivery. Coomarasamy A. Fetal Medicine Foundation Second Trimester Screening Group. 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. Alfirevic Z. Copper RL. 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. Hassan SS. Nicolaides KH. Heath VC. Elisseou A. 2. O'Brien JM. Gajewska K. 4. Ville Y. The use of progesterone is discussed in more detail in a separate RANZCOG clinical guideline (CObs 29b). Mercer BM. Nicolaides K. Johnson F. Nicolaides KH. 33 (4): 459-64. Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review.11 There may. Smith GC. Southall TR. 7. Approximately 11 women need to be treated to prevent one preterm delivery <34 weeks.13 • • References 1. 6. Treatment with progesterone reduces the risk of preterm delivery <34 weeks by 42% and reduces neonatal morbidity. Soma-Pillay P. Klein K. Tabor A. 12 (5): 312-7. Gupta JK. Salomon LJ. especially previous history of preterm birth. may benefit from cervical cerclage. Iams JD. Am J Obstet Gynecol 2012. Romero R. Conde-Agudelo A.10. Creasy GW. 31 (5): 549-54.8 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. Southall TR. Ultrasound Obstet Gynecol 2008. 3. Khan KS. Ultrasound Obstet Gynecol 1998. 206: 124. Bernard JP.e1-124. Celik E. Bachmann LM. Moawad A. 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. Novakov A. Thom E. Nicolaides KH. 5. Ultrasound Obstet Gynecol 2003. Meis PJ. DaFonseca E. Roberts JM. Reference range for cervicallength throughout pregnancy: non-parametric LMS-based model applied to a largesample. Rode L. Souka AP. Kleijnen J. Fusey S. Goldenberg RL. Ultrasound Obstet Gynecol 2009.

13.8. Klein K. Links to other College statements (C-Gen 15) Evidence-based Medicine. Groom KM. 10. Nicolaides KH. 25 (4): 353-6. Elective cervical cerclage versus serial ultrasound surveillance of cervical length in a population at high risk for preterm delivery. 3 RANZCOGCollege Statement: C-Obs 27 . Obstetrics and Gynaecology http://www. 203 (2): 128. and the application of this statement in each case.html 9. 106 (1): 181-9. Berghella V. Rane S. Golara M. Althuisius SM. Shennan AH. Bennett PR. In particular. clinical management must always be responsive to the needs of the individual patient and the particular circumstances of each case. RANZCOG College Statement C-Obs 29: Progesterone: Use in the Second and Third Trimester of Pregnancy for the Prevention of Preterm Birth. Odibo AO. Ultrasound Obstet Gynecol 2005. and each Practitioner must have regard to relevant information.e1-12. 112 (2): 158-61. research or material which may have been published or become available subsequently. Hassan SS. 12. It is the responsibility of each Practitioner to have regard to the particular circumstances of each case. Sonographic measurement of cervical length in threatened preterm labor in singleton pregnancies with intact membranes. Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation. Romero R. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Vaginal micronized progesterone and risk of preterm delivery in high-risk twin pregnancies: secondary analysis of a placebo-controlled randomized trial and metaanalysis. To MS.html?Itemid=341 Disclaimer This College Statement is intended to provide general advice to Practitioners. Rode L.ranzcog. Krampl-Bettelheim Rust OA. Available at: http://www. The statement has been prepared having regard to general circumstances. Geerts L. 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. Fuchs IB. PREDICT Group. This College statement has been prepared having regard to the information available at the time of its preparation. Nicolaides KH. Tsoi E. Obstet Gynecol 2005. Conde-Agudelo Thalon A. it takes no responsibility for matters arising from changed circumstances or information or material that may have become available after the date of the Ultrasound Obstet Gynecol 2011. Transvaginal sonographic cervical length for the prediction of spontaneous preterm birth in twin pregnancies: a systematic review and metaanalysis. Tabor A. 38 (3): 281-7. Am J Obstet Gynecol 2010. Eur J Obstet Gynecol Reprod Biol 2004.ranzcog. Yeo L.

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