Cervical length

for
Preterm birth
prevention
Society for Maternal-Fetal
Medicine, 2016

Prof. Aboubakr
Elnashar
Benha University Hospital
Egypt

ABOUBAKR ELNASHAR
 CONTENTS
1. CLINICAL SIGNIFICANCE OF A
SONOGRAPHICALLY SHORT CERVIX
2. TRANSABDOMINAL OR TRANSVAGINAL
ULTRASOUND
3. STEPS FOR PROPER CERVICAL LENGTH
MEASUREMENT
4. WHEN TO ASSESS CLDURING PREGNANCY
5. CERVICAL LENGTH SCREENING
6. PREVENTION

ABOUBAKR ELNASHAR
PTB
2/3 are spontaneous
recurrence risks are high
Few tests are available to predict which pregnancies
will deliver preterm
TV cervical length (CL) measurement
an important clinical tool to identify women at high
risk for PTB
allow for interventions to prevent, delay, or prepare
for PTB.

ABOUBAKR ELNASHAR
 1. CLINICAL SIGNIFICANCE OF A
SONOGRAPHICALLY SHORT CERVIX
Women with a history of a prior spontaneous PTB
account for:
10% of all births < 34 weeks of gestation.
Mid-trimester CL assessment by TVS:
the best clinical predictor of spontaneous PTB.
Short CL
20-30 mm
Depending on
the population studied
gestational age of assessment

ABOUBAKR ELNASHAR
Short CL
irrespective of prior pregnancy history
has been consistently and reproducibly associated
with an elevated risk of spontaneous PTB across
different gestational age cutoffs and multiple patient
populations
Short CL with a history of a prior spontaneous PTB
at the highest risk of PTB
(Iams JD, Berghella, 2010)

ABOUBAKR ELNASHAR
 2. Transabdominal or transvaginal ultrasound
TVS:
 safe
gold standard’ for measurement CL.
TV vs TA:
highly reproducible
unaffected by maternal obesity, cervical position,
and shadowing from fetal parts
more sensitive
low interobserver variation rate: 5-10%.

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 3. STEPS FOR PROPER CERVICAL LENGTH MEASUREMENT
1. Ensure patient has emptied her bladder.
2. Prepare the cleaned probe using a probe cover.
3. Gently insert the probe into the patient’s vagina.
4. Guide the probe into the anterior fornix.
5. Obtain a sagittal, long-axis image of the entire cervix.
6. Remove the probe until the image blurs and then reinsert
gently until the image clears (this ensures you are not using
excessive pressure)
7. Enlarge the image so that the cervix occupies two thirds of the
screen.
8. Ensure both the internal and external os are seen clearly.
9. Measure the cervical length along the endocervical canal
between the internal and external os.
10. Repeat this process twice to obtain 3 sets of images/
measurements.
11. Use the shortest best measurement.
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Schematic representation of transvaginal ultrasonographic
cervical measurements
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Transabdominal ultrasound
Full bladder: compression and artificial lengthening of the cervix.

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Transvaginal ultrasound image of the cervix
cervical length, 38.7 mm
the lower uterine segment (arrows) is still closed and should not
be included in the cervical length.
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Transvaginal ultrasound image of short cervix (20.6 mm).
ABOUBAKR ELNASHAR
Transvaginal ultrasound image of short cervix
(9.3 mm) with funneling and amniotic fluid
sludge (arrow).

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Transvaginal ultrasound image showing dilated internal
(solid arrow) and external (dashed arrow) ora.
Note cervical length (closed portion of cervix) cannot be measured
in such cases.
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Transvaginal ultrasound image of cervix showing
echogenic lines of cervical cerclage (arrow) at level of internal
os.

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 4. WHEN TO ASSESS CL DURING PREGNANCY
Between 16 and 24 w.
Prior to 16 w
1. the lower uterine segment is underdeveloped: challenging
to distinguish this area from the endocervical canal
2. first and early second trimester CL had not consistently
shown adequate predictive value of CL measurement for
preterm birth.
Beyond 24weeks
1. interventions (cerclage, vaginal progesterone) used 24 w
as the upper gestational age limit for screening and
initiation of therapies or interventions
2. Provide limited clinical value and there is absence of data
to suggest it improves outcomes.

ABOUBAKR ELNASHAR
 5. CERVICAL LENGTH SCREENING
The approach to CL screening varies based on patient
characteristics and risk factors.
I. Women with a prior spontaneous PTB
SMFM and ACOG, 2012 guidelines
 women with a prior spontaneous PTB undergo CL
screening with TVS.
 Performed (every 1-2 w as determined by the
clinical situation)
 from 16 until 24 w.
(GRADE 1A)

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The issue of universal TV CL screening of singleton
gestations without prior PTB for the prevention of PTB
remains an object of debate.

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II. Other special situations
1. History of treatment for cervical dysplasia
There is insufficient evidence to support additional
screening for women with, LEEP or cold knife cone
for cervical dysplasia.

ABOUBAKR ELNASHAR
2. Multiple gestation
Available data does not indicate adequate clinical
benefit
3. Preterm PROM
insufficient data to suggest clinical benefit.
4. Placenta previa (grade 2B)
No prospective studies testing a management
strategy based on CL
insufficient data to suggest a proven clinical
benefit

ABOUBAKR ELNASHAR
5. After cerclage placement
Neither overall CL nor length below the
stitch correlate well with outcomes
No additional tt for a short cervix after cerclage (e.g.
reinforcement suture does
not improve outcomes)
Insufficient data for benefit

ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Maternal –Fetal medicine Society,
2012

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You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/

2.Slide share web site

3.elnashar53@hotmail.com
4.My clinic Althawra st. Mansura
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