Cervical Funneling – False Positive and False Negative Observations

B. Arabin
Clara Angela Foundation / Isala Clinics (Sophia), Zwolle, The Netherlands

Summary Transvaginal sonography (TVS) was performed longitudinally in singleton, twin and triplet pregnancies in a supine and upright position. An opening of the internal os was more pronounced in multiple compared to singleton pregnancies and earlier and more frequently observed in an upright position. In patients with preterm birth an opening of the internal os in an upright position combined with cervico-vaginal fibronectin was the most significant parameter to predict prematurity. In risk populations, we emphasize longitudinal examinations by TVS to increase the chance to recognize symptoms in a reversible instead of an irreversible phase and to evaluate whether maternal postural challenge assists in predicting patients at risk for premature delivery. Introduction Cervical shortening and opening of the internal os as seen by TVS, are detected weeks before preterm birth, providing evidence that spontaneous preterm birth is the result of a long-term process with a dilated cervix as the common terminal pathway. The structure of the cervix depends on the regulation of connective tissue. Cervical ripening and a change in its mechanical properties is characterized by an increase of collagen solubility and collagenolytic activity and a decrease of collagen content partly mediated by proteoaminoglycans1. During cervical ripening an influx of inflammatory cells may induce increasing levels of cytokines and prostaglandins2. In humans, detection of an estriol surge can identify women at elevated risk for preterm birth 3 weeks before delivery3. Papiernik et al.4 examined the relationship between cervical ripening and prematurity in a high risk population of more than 8000 pregnant women. Dilatation of the internal os was found to be the most significant risk factor for preterm delivery. However, routine pelvic examination was not shown to be predictive of preterm labor which might be attributed to the fact that the opening of the internal os is not detected by digital cervical examination5. Currently, it is accepted that TVS is better than digital examination as a predictor of the likelihood of premature delivery. Thereby maternal postural challenge has been performed by only a few groups6,7,8. Aim of our study was to perform longitudinal measurements of the cervical length, the width of the internal os in both a supine and upright position and determine the prognostic value. Material and Methods

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114 Arabin . the funnel width and cervical length both in a supine and upright position. cervicovaginal fibronectin. the Bishop score. we have indicated interventions. e. Multiple logistic regression revealed that in both considered intervals. Values between the two positions were significantly different from 20 weeks onwards. specificity. history of preterm delivery. In the longitudinal group the cervical length and width of the internal os (funneling) and the position of the cervix were determined from ultrasound pictures. between 20 and 24+6 weeks and between 25 and 29+6 weeks funnel width in an upright position and the detection of fibronectin were the most ding significant independent variables to diagnose subsequent preterm birth for singleton and multiple pregnancies. fibronectin. digital examination and cervical culture at around 25 weeks. In pregnancies with spontaneous onset of birth.From 1994-96. positive and negative predictive values are summarized in Table 1 separate for singleton and twin pregnancies. in normal singleton pregnancies only above 35 gestational weeks. Results Cervical length decreased significantly from 15 weeks to term in both supine and upright position and in singleton and multiple gestation. we demonstrated that the rate of preterm deliveries decreased in both singleton and multiple pregnancies with the application of early longitudinal TVS. Significant funneling was observed only in a standing position in all groups. patients with singleton pregnancy and a history of prematurity or premature contractions as well as with twin pregnancy (n= 247) were screened by TVS. Sensitivity. voluntary abortion. Differences in funneling between the positions were significant from 30 weeks in normal singleton and from 25 weeks in multiple gestation in the standing position. funneling was significant from 20 weeks onwards in an upright and from 25 weeks in a recumbent position in both singleton and multiple gestation. the application of a vaginal cervix pessary based on TVS findings. Independent variables included age. miscarriage. in normal twin pregnancies from 30 weeks and in triplet pregnancies from 20 weeks onwards.g. conization. uterine malformations. comparable groups with singleton and twin gestation (n=241) were longitudinally examined in a supine and upright position from 15 weeks onwards.g. including information to the patient and an increased indication of the pessary. We determined the value of longitudinal measurements by TVS in comparison to common diagnostic tools between 20 and 24+6 and between 25 and 29+6 gestational weeks. bacterial swab. the registration of contractions. From 1997-99. In this group. Using historic controls. parity. e. tocography.

67:238-42 5) Buekens P. van Eyck J. Ripening of the human uterine cervix related to changes in collagen. Interleukin-8 synthesis and the onset of labor. Ekman G. 83: 248-52 Table 1 a and b) Diagnostic value of the most significant combination to determine the risk of spontaneous onset of preterm birth (multivariate regression): Funnel width in a standing position (ST) without or with fibronectin. A new method using vaginal ultrasound and transfundal pressure to evaluate the asymptomatic incompetent cervix. 344:841-4 6) Arabin B. glycosaminoglycans and collagenolytic activity. Houlihan C. J Ultrasound Med 1997. Obstet Gynecol 1994. et al. Lachelin GCL et al. Prospective studies are needed to corroborate the preliminary results. Precocious cervical ripening and labor. Preliminary observations.Discussion and Conclusions Risks previously considered as “distinct causes” are viewed instead as continuous variables. Collin D. Obstet Gynecol 1986. Aardenburg R. Boutsen M. 42: 719-24 7) Wong G. Jackson GM. 173: 1337-42 4) Papiernik E. European Community Collaborative Study Group on Prenatal Screening. Randomised controlled trial of routine cervical examinations in pregnancy. Tschesche H. 147: 662-6 2) Osmers R. Obstet Gynecol 1995. Levine D. Maternal position and ultrasonic cervical assess-ment in multiple pregnancy. Am J Obstet Gynecol 1995. References 1) Uldbjerg N. Ludmir J. 86: 223-29 3) Mc Gregor JA. J Reprod Med 1997. To our opinion. Salivary estriol as risk assessment for preterm labor: A prospective trial. Alexander S. Kuhn W. Rosenberg JC. Lancet 1994. Malstrom A. Blaser J. Maternal postural challenge as a functional test for cervical incompetence. determined at different intervals during pregnancy a) in 102 singleton pregnancies at risk for preterm birth b) in 106 twin pregnancies 114 Arabin . Am J Obstet Gynecol 1982. et al. Bouyer J. longitudinal measurements by TVS possibly with postural stress are recommended in risk patients for preterm birth and should be combined with biochemical markers. 16: 169-75 8) Guzman ER.

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