Download PDF
Am J Perinatol 2016; 33(03): 245-252
DOI: 10.1055/s-0035-1571145
Prematurity Special Issue
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Short Cervix during Pregnancy: A Review

Jennifer Gilner
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
,
Joseph Biggio
2   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
› Author Affiliations
Further Information

Publication History

18 November 2015

24 November 2015

Publication Date:
20 January 2016 (online)

    Permissions and Reprints

Abstract

Sonographic evaluation of the uterine cervix has evolved as one of the best clinical tools available for the prediction of subsequent spontaneous preterm birth (PTB), particularly when combined with prior poor obstetric history. There is a growing body of evidence describing interventions for short cervix that reduce the risk of preterm delivery and improve neonatal outcomes. Yet, given the significant heterogeneity in the pathways that lead to PTB, understanding the specific clinical characteristics of women who may benefit from a given intervention is critical to appropriate implementation. The three primary management strategies that have demonstrated improvement in obstetric and/or perinatal outcomes for appropriately selected women with a sonographically short cervix (vaginal progesterone, cervical cerclage, and pessary) are the subject of this review. In addition, the unique considerations of multiple pregnancies are discussed separately from singletons.

Keywords

preterm birth - short cervix - cervical insufficiency - progesterone - cervical cerclage - cervical pessary

Note

Dr. Biggio has previously received a community education grant from Lumara Health.


 

  • References

  • 1 Romero R, Yeo L, Miranda J, Hassan SS, Conde-Agudelo A, Chaiworapongsa T. A blueprint for the prevention of preterm birth: vaginal progesterone in women with a short cervix. J Perinat Med 2013; 41 (1) 27-44
    CrossrefPubMedGoogle Scholar
  • 2 Andersen HF, Nugent CE, Wanty SD, Hayashi RH. Prediction of risk for preterm delivery by ultrasonographic measurement of cervical length. Am J Obstet Gynecol 1990; 163 (3) 859-867
    CrossrefPubMedGoogle Scholar
  • 3 Iams JD, Goldenberg RL, Meis PJ , et al; National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. The length of the cervix and the risk of spontaneous premature delivery. N Engl J Med 1996; 334 (9) 567-572
    CrossrefPubMedGoogle Scholar
  • 4 Owen J, Yost N, Berghella V , et al; National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network. Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth. JAMA 2001; 286 (11) 1340-1348
    CrossrefPubMedGoogle Scholar
  • 5 Guzman ER, Ananth CV. Cervical length and spontaneous prematurity: laying the foundation for future interventional randomized trials for the short cervix. Ultrasound Obstet Gynecol 2001; 18 (3) 195-199
    CrossrefPubMedGoogle Scholar
  • 6 Berghella V, Roman A, Daskalakis C, Ness A, Baxter JK. Gestational age at cervical length measurement and incidence of preterm birth. Obstet Gynecol 2007; 110 (2 Pt 1) 311-317
    CrossrefPubMedGoogle Scholar
  • 7 Sonek JD, Iams JD, Blumenfeld M, Johnson F, Landon M, Gabbe S. Measurement of cervical length in pregnancy: comparison between vaginal ultrasonography and digital examination. Obstet Gynecol 1990; 76 (2) 172-175
    PubMedGoogle Scholar
  • 8 Burger M, Weber-Rössler T, Willmann M. Measurement of the pregnant cervix by transvaginal sonography: an interobserver study and new standards to improve the interobserver variability. Ultrasound Obstet Gynecol 1997; 9 (3) 188-193
    CrossrefPubMedGoogle Scholar
  • 9 Sonek J, Shellhaas C. Cervical sonography: a review. Ultrasound Obstet Gynecol 1998; 11 (1) 71-78
    CrossrefPubMedGoogle Scholar
  • 10 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
    CrossrefPubMedGoogle Scholar
  • 11 Hernandez-Andrade E, Romero R, Ahn H , et al. Transabdominal evaluation of uterine cervical length during pregnancy fails to identify a substantial number of women with a short cervix. J Matern Fetal Neonatal Med 2012; 25 (9) 1682-1689
    CrossrefPubMedGoogle Scholar
  • 12 Vaisbuch E, Romero R, Mazaki-Tovi S , et al. The risk of impending preterm delivery in asymptomatic patients with a nonmeasurable cervical length in the second trimester. Am J Obstet Gynecol 2010; 203 (5) 446.e1-446.e9
    CrossrefPubMedGoogle Scholar
  • 13 Werner EF, Han CS, Pettker CM , et al. Universal cervical-length screening to prevent preterm birth: a cost-effectiveness analysis. Ultrasound Obstet Gynecol 2011; 38 (1) 32-37
    PubMedGoogle Scholar
  • 14 Cahill AG, Odibo AO, Caughey AB , et al. Universal cervical length screening and treatment with vaginal progesterone to prevent preterm birth: a decision and economic analysis. Am J Obstet Gynecol 2010; 202 (6) 548.e1-548.e8
    CrossrefPubMedGoogle Scholar
  • 15 Berghella V, Figueroa D, Szychowski JM , et al; Vaginal Ultrasound Trial Consortium. 17-alpha-hydroxyprogesterone caproate for the prevention of preterm birth in women with prior preterm birth and a short cervical length. Am J Obstet Gynecol 2010; 202 (4) 351.e1-351.e6
    CrossrefPubMedGoogle Scholar
  • 16 O'Brien JM, Adair CD, Lewis DF , et al. Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2007; 30 (5) 687-696
    CrossrefPubMedGoogle Scholar
  • 17 DeFranco EA, O'Brien JM, Adair CD , et al. Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2007; 30 (5) 697-705
    CrossrefPubMedGoogle Scholar
  • 18 O'Brien JM, Defranco EA, Adair CD , et al; Progesterone Vaginal Gel Study Group. Effect of progesterone on cervical shortening in women at risk for preterm birth: secondary analysis from a multinational, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2009; 34 (6) 653-659
    CrossrefPubMedGoogle Scholar
  • 19 Grobman WA, Thom EA, Spong CY , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network. 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm. Am J Obstet Gynecol 2012; 207 (5) 390.e1-390.e8
    CrossrefPubMedGoogle Scholar
  • 20 Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH ; Fetal Medicine Foundation Second Trimester Screening Group. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007; 357 (5) 462-469
    CrossrefPubMedGoogle Scholar
  • 21 Hassan SS, Romero R, Vidyadhari D , et al; PREGNANT Trial. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011; 38 (1) 18-31
    PubMedGoogle Scholar
  • 22 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.e1-124.e19
    CrossrefPubMedGoogle Scholar
  • 23 Society for Maternal-Fetal Medicine Publications Committee, with assistance of Vincenzo Berghella. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol 2012; 206 (5) 376-386
    CrossrefPubMedGoogle Scholar
  • 24 Rode L, Klein K, Nicolaides KH, Krampl-Bettelheim E, Tabor A ; PREDICT Group. Prevention of preterm delivery in twin gestations (PREDICT): a multicenter, randomized, placebo-controlled trial on the effect of vaginal micronized progesterone. Ultrasound Obstet Gynecol 2011; 38 (3) 272-280
    PubMedGoogle Scholar
  • 25 Cetingoz E, Cam C, Sakallı M, Karateke A, Celik C, Sancak A. Progesterone effects on preterm birth in high-risk pregnancies: a randomized placebo-controlled trial. Arch Gynecol Obstet 2011; 283 (3) 423-429
    CrossrefPubMedGoogle Scholar
  • 26 Ransom CE, Murtha AP. Progesterone for preterm birth prevention. Obstet Gynecol Clin North Am 2012; 39 (1) 1-16 , vii
    CrossrefPubMedGoogle Scholar
  • 27 Parry S, Simhan H, Elovitz M, Iams J. Universal maternal cervical length screening during the second trimester: pros and cons of a strategy to identify women at risk of spontaneous preterm delivery. Am J Obstet Gynecol 2012; 207 (2) 101-106
    CrossrefPubMedGoogle Scholar
  • 28 Berghella V, Szychowski JM, Owen J , et al; Vaginal Ultrasound Trial Consortium. Suture type and ultrasound-indicated cerclage efficacy. J Matern Fetal Neonatal Med 2012; 25 (11) 2287-2290
    CrossrefPubMedGoogle Scholar
  • 29 Davis G, Berghella V, Talucci M, Wapner RJ. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol 2000; 183 (4) 836-839
    CrossrefPubMedGoogle Scholar
  • 30 American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 2014; 123 (2 Pt 1) 372-379
    CrossrefPubMedGoogle Scholar
  • 31 Rust OA, Atlas RO, Reed J, van Gaalen J, Balducci J. Revisiting the short cervix detected by transvaginal ultrasound in the second trimester: why cerclage therapy may not help. Am J Obstet Gynecol 2001; 185 (5) 1098-1105
    CrossrefPubMedGoogle Scholar
  • 32 Althuisius SM, Dekker GA, Hummel P, Bekedam DJ, van Geijn HP. Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol 2001; 185 (5) 1106-1112
    CrossrefPubMedGoogle Scholar
  • 33 To MS, Alfirevic Z, Heath VC , et al; Fetal Medicine Foundation Second Trimester Screening Group. Cervical cerclage for prevention of preterm delivery in women with short cervix: randomised controlled trial. Lancet 2004; 363 (9424) 1849-1853
    CrossrefPubMedGoogle Scholar
  • 34 Berghella V, Odibo AO, Tolosa JE. Cerclage for prevention of preterm birth in women with a short cervix found on transvaginal ultrasound examination: a randomized trial. Am J Obstet Gynecol 2004; 191 (4) 1311-1317
    CrossrefPubMedGoogle Scholar
  • 35 Owen J, Hankins G, Iams JD , et al. Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length. Am J Obstet Gynecol 2009; 201 (4) 375.e1-375.e8
    CrossrefPubMedGoogle Scholar
  • 36 Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol 2011; 117 (3) 663-671
    CrossrefPubMedGoogle Scholar
  • 37 Berghella V, Mackeen AD. Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis. Obstet Gynecol 2011; 118 (1) 148-155
    CrossrefPubMedGoogle Scholar
  • 38 Berghella V, Haas S, Chervoneva I, Hyslop T. Patients with prior second-trimester loss: prophylactic cerclage or serial transvaginal sonograms?. Am J Obstet Gynecol 2002; 187 (3) 747-751
    CrossrefPubMedGoogle Scholar
  • 39 Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005; 106 (1) 181-189
    CrossrefPubMedGoogle Scholar
  • 40 Cross RG. Treatment of habitual abortion due to cervical incompetence. Lancet 1959; 274 (7094) 127
    PubMedGoogle Scholar
  • 41 Newcomer J. Pessaries for the treatment of incompetent cervix and premature delivery. Obstet Gynecol Surv 2000; 55 (7) 443-448
    CrossrefPubMedGoogle Scholar
  • 42 Dharan VB, Ludmir J. Alternative treatment for a short cervix: the cervical pessary. Semin Perinatol 2009; 33 (5) 338-342
    CrossrefPubMedGoogle Scholar
  • 43 Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA. Cervical pessary for preventing preterm birth. Cochrane Database Syst Rev 2013; 5: CD007873
    PubMedGoogle Scholar
  • 44 Arabin B, Alfirevic Z. Cervical pessaries for prevention of spontaneous preterm birth: past, present and future. Ultrasound Obstet Gynecol 2013; 42 (4) 390-399
    PubMedGoogle Scholar
  • 45 Arabin B, Halbesma JR, Vork F, Hübener M, van Eyck J. Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix?. J Perinat Med 2003; 31 (2) 122-133
    CrossrefPubMedGoogle Scholar
  • 46 Acharya G, Eschler B, Grønberg M, Hentemann M, Ottersen T, Maltau JM. Noninvasive cerclage for the management of cervical incompetence: a prospective study. Arch Gynecol Obstet 2006; 273 (5) 283-287
    CrossrefPubMedGoogle Scholar
  • 47 Sieroszewski P, Jasiński A, Perenc M, Banach R, Oszukowski P. The Arabin pessary for the treatment of threatened mid-trimester miscarriage or premature labour and miscarriage: a case series. J Matern Fetal Neonatal Med 2009; 22 (6) 469-472
    CrossrefPubMedGoogle Scholar
  • 48 To MS, Skentou C, Liao AW, Cacho A, Nicolaides KH. Cervical length and funneling at 23 weeks of gestation in the prediction of spontaneous early preterm delivery. Ultrasound Obstet Gynecol 2001; 18 (3) 200-203
    CrossrefPubMedGoogle Scholar
  • 49 Goya M, Pratcorona L, Merced C , et al; Pesario Cervical para Evitar Prematuridad (PECEP) Trial Group. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet 2012; 379 (9828) 1800-1806
    CrossrefPubMedGoogle Scholar
  • 50 Hui SY, Chor CM, Lau TK, Lao TT, Leung TY. Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial. Am J Perinatol 2013; 30 (4) 283-288
    Article in Thieme ConnectPubMedGoogle Scholar
  • 51 Alfirevic Z, Owen J, Carreras Moratonas E, Sharp AN, Szychowski JM, Goya M. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix. Ultrasound Obstet Gynecol 2013; 41 (2) 146-151
    CrossrefPubMedGoogle Scholar
  • 52 Conde-Agudelo A, Romero R, Nicolaides K , et al. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208 (1) 42.e1-42.e18
    CrossrefPubMedGoogle Scholar
  • 53 Martin JA, Hamilton BE, Osterman MJ. Three decades of twin births in the United States, 1980-2009. NCHS Data Brief 2012; (80) 1-8
    PubMedGoogle Scholar
  • 54 Gyamfi C, Lerner V, Holzman I, Stone JL. Routine cervical length in twins and perinatal outcomes. Am J Perinatol 2007; 24 (1) 65-69
    Article in Thieme ConnectPubMedGoogle Scholar
  • 55 To MS, Fonseca EB, Molina FS, Cacho AM, Nicolaides KH. Maternal characteristics and cervical length in the prediction of spontaneous early preterm delivery in twins. Am J Obstet Gynecol 2006; 194 (5) 1360-1365
    CrossrefPubMedGoogle Scholar
  • 56 Biggio JR, Anderson S. Spontaneous preterm birth in multiples. Clin Obstet Gynecol 2015; 58 (3) 654-667
    CrossrefPubMedGoogle Scholar
  • 57 Rouse DJ, Caritis SN, Peaceman AM , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins. N Engl J Med 2007; 357 (5) 454-461
    CrossrefPubMedGoogle Scholar
  • 58 Caritis SN, Rouse DJ, Peaceman AM , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU). Prevention of preterm birth in triplets using 17 alpha-hydroxyprogesterone caproate: a randomized controlled trial. Obstet Gynecol 2009; 113 (2 Pt 1) 285-292
    Google Scholar
  • 59 Combs CA, Garite T, Maurel K, Das A, Porto M ; Obstetrix Collaborative Research Network. 17-hydroxyprogesterone caproate for twin pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol 2011; 204 (3) 221.e1-221.e8
    CrossrefPubMedGoogle Scholar
  • 60 Senat MV, Porcher R, Winer N , et al; Groupe de Recherche en Obstétrique et Gynécologie. Prevention of preterm delivery by 17 alpha-hydroxyprogesterone caproate in asymptomatic twin pregnancies with a short cervix: a randomized controlled trial. Am J Obstet Gynecol 2013; 208 (3) 194.e1-194.e8
    Google Scholar
  • 61 Durnwald CP, Momirova V, Rouse DJ , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-α hydroxyprogesterone caproate. J Matern Fetal Neonatal Med 2010; 23 (12) 1360-1364
    CrossrefPubMedGoogle Scholar
  • 62 Klein K, Rode L, Nicolaides KH, Krampl-Bettelheim E, Tabor A ; PREDICT Group. Vaginal micronized progesterone and risk of preterm delivery in high-risk twin pregnancies: secondary analysis of a placebo-controlled randomized trial and meta-analysis. Ultrasound Obstet Gynecol 2011; 38 (3) 281-287
    CrossrefPubMedGoogle Scholar
  • 63 Newman RB, Krombach RS, Myers MC, McGee DL. Effect of cerclage on obstetrical outcome in twin gestations with a shortened cervical length. Am J Obstet Gynecol 2002; 186 (4) 634-640
    CrossrefPubMedGoogle Scholar
  • 64 Saccone G, Rust O, Althuisius S, Roman A, Berghella V. Cerclage for short cervix in twin pregnancies: systematic review and meta-analysis of randomized trials using individual patient-level data. Acta Obstet Gynecol Scand 2015; 94 (4) 352-358
    CrossrefPubMedGoogle Scholar
  • 65 Roman A, Rochelson B, Fox NS , et al. Efficacy of ultrasound-indicated cerclage in twin pregnancies. Am J Obstet Gynecol 2015; 212 (6) 788.e1-788.e6
    CrossrefPubMedGoogle Scholar
  • 66 Miller ES, Rajan PV, Grobman WA. Outcomes after physical examination-indicated cerclage in twin gestations. Am J Obstet Gynecol 2014; 211 (1) 46.e1-46.e5
    CrossrefPubMedGoogle Scholar
  • 67 Rebarber A, Bender S, Silverstein M, Saltzman DH, Klauser CK, Fox NS. Outcomes of emergency or physical examination-indicated cerclage in twin pregnancies compared to singleton pregnancies. Eur J Obstet Gynecol Reprod Biol 2014; 173: 43-47
    CrossrefPubMedGoogle Scholar
  • 68 Liem S, Schuit E, Hegeman M , et al. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): a multicentre, open-label randomised controlled trial. Lancet 2013; 382 (9901) 1341-1349
    CrossrefPubMedGoogle Scholar
  • 69 Nicolaides KH, Syngelaki A, Poon LC , et al. Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial. Am J Obstet Gynecol 2016; 214: 3.e1-3.e9
    CrossrefPubMedGoogle Scholar