Proposed staging criteria for sonographic and physical exam for cervical changes at <24 weeks gestation to predict preterm birth

Published:September 18, 2022DOI:
      Asymptomatic cervical changes, such as cervical length shortening and dilation, which often occur before spontaneous preterm birth, have been described well in singleton pregnancies with or without history of preterm birth. The current screening strategies available to identify patients at increased risk of spontaneous preterm birth include use of transvaginal ultrasound for cervical length assessment and for detection of a short cervical length (≤25 mm) before 24 weeks of gestation. Whether an additional evaluation of the cervix (ie, via speculum or manual exam) is indicated is often pondered by clinicians and may depend on how short the cervical length is and if there is a history of preterm birth. Based on expert opinion, we developed a novel staging system of asymptomatic cervical changes including the following: cervical length measurement, cervical and membrane appearance on speculum exam, and cervical dilation by manual exam. This staging system, if proven accurate, may aid in standardizing definitions for purposes of patient prognosis, evaluation of intervention efficacy, and clinical management.


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        • Martin JA
        • Hamilton BE
        • Osterman MJK
        • Driscoll AK.
        Births: final data for 2019.
        Natl Vital Stat Rep. 2021; 70: 1-51
        • Murphy SL
        • Mathews TJ
        • Martin JA
        • Minkovitz CS
        • Strobino DM.
        Annual summary of vital statistics: 2013-2014.
        Pediatrics. 2017; 139e20163239
        • Grimes-Dennis J
        • Berghella V.
        Cervical length and prediction of preterm delivery.
        Curr Opin Obstet Gynecol. 2007; 19: 191-195
        • 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: 567-572
        • Owen J
        • Yost N
        • Berghella V
        • et al.
        Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth.
        JAMA. 2001; 286: 1340-1348
        • Heath VC
        • Southall TR
        • Souka AP
        • Elisseou A
        • Nicolaides KH.
        Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery.
        Ultrasound Obstet Gynecol. 1998; 12: 312-317
        • 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 (e1–9): 446
        • Boelig RC
        • Kripalu V
        • Chen SL
        • Cruz Y
        • Roman A
        • Berghella V.
        Utility of follow-up cervical length screening in low-risk women with a cervical length of 26 to 29 mm.
        Am J Obstet Gynecol. 2021; 225 (e1–6): 179
        • Enakpene CA
        • DiGiovanni L
        • Jones TN
        • Marshalla M
        • Mastrogiannis D
        • Della Torre M
        Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening.
        Am J Obstet Gynecol. 2018; 219 (e1–10): 397
        • Berghella V
        • Tolosa JE
        • Kuhlman K
        • Weiner S
        • Bolognese RJ
        • Wapner RJ.
        Cervical ultrasonography compared with manual examination as a predictor of preterm delivery.
        Am J Obstet Gynecol. 1997; 177: 723-730
        • Groom KM
        • Shennan AH
        • Bennett PR.
        Ultrasound-indicated cervical cerclage: outcome depends on preoperative cervical length and presence of visible membranes at time of cerclage.
        Am J Obstet Gynecol. 2002; 187: 445-449
        • Boelig RC
        • Dugoff L
        • Roman A
        • Berghella V
        • Ludmir J.
        Predicting asymptomatic cervical dilation in pregnant patients with short mid-trimester cervical length: a secondary analysis of a randomized controlled trial.
        Acta obstet gynecol Scand. 2019; 98: 761-768
        • Zafman KB
        • Rebarber A
        • Fox NS.
        Serial cervical length evaluation in low-risk women with shortened cervical lengths in the midtrimester: how many will dilate prior to 24 weeks?.
        Am J Perinatol. 2020; 37: 14-18
        • Shahawy S
        • Henricks AA
        • Chow KY
        • Saladi NU
        • Saade GR
        • Miller ES.
        The role of digital examination in the setting of a sonographically short cervix.
        Am J Obstet Gynecol MFM. 2022; 4100650
        • Romero R
        • Miranda J
        • Chaiworapongsa T
        • et al.
        Sterile intra-amniotic inflammation in asymptomatic patients with a sonographic short cervix: prevalence and clinical significance.
        J Matern Fetal Neonatal Med. 2015; 28: 1343-1359
        • Romero R
        • Gonzalez R
        • Sepulveda W
        • et al.
        Infection and labor. VIII. Microbial invasion of the amniotic cavity in patients with suspected cervical incompetence: prevalence and clinical significance.
        Am J Obstet Gynecol. 1992; 167: 1086-1091
        • Ehsanipoor RM
        • Seligman NS
        • Saccone G
        • et al.
        Physical examination-indicated cerclage: a systematic review and meta-analysis.
        Obstet Gynecol. 2015; 126: 125-135
        • Bigelow CA
        • Naqvi M
        • Namath AG
        • Ali M
        • Fox NS.
        Cervical length, cervical dilation, and gestational age at cerclage placement and the risk of preterm birth in women undergoing ultrasound or exam indicated Shirodkar cerclage.
        J Matern Fetal Neonatal Med. 2020; 33: 2527-2532
        • Roman A
        • Saccone G
        • Pachtman S
        • et al.
        Predictors of preterm birth after physical exam indicated cerclage in singleton pregnancy.
        Am J Obstet Gynecol. 2018; 218: S106-S107
        • Romero R
        • Conde-Agudelo A
        • Da Fonseca E
        • et al.
        Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data.
        Am J Obstet Gynecol. 2018; 218: 161-180
        • 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: 663-671
        • Berghella V
        • Ciardulli A
        • Rust OA
        • et al.
        Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.
        Ultrasound Obstet Gynecol. 2017; 50: 569-577
        • Szychowski JM
        • Owen J
        • Hankins G
        • et al.
        Can the optimal cervical length for placing ultrasound-indicated cerclage be identified?.
        Ultrasound Obstet Gynecol. 2016; 48: 43-47
      1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Prediction and prevention of spontaneous preterm birth: ACOG Practice Bulletin, Number 234.
        Obstet Gynecol. 2021; 138: e65-e90
        • McIntosh J
        • Feltovich H
        • Berghella V
        • Manuck T.
        • Society for Maternal-Fetal Medicine (SMFM)
        The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention.
        Am J Obstet Gynecol. 2016; 215 (Electronic address: [email protected]): B2-B7
        • Zilianti M
        • Azuaga A
        • Calderon F
        • Pagés G
        • Mendoza G.
        Monitoring the effacement of the uterine cervix by transperineal sonography: a new perspective.
        J Ultrasound Med. 1995; 14: 719-724
        • Berghella V
        • Owen J
        • MacPherson C
        • et al.
        Natural history of cervical funneling in women at high risk for spontaneous preterm birth.
        Obstet Gynecol. 2007; 109: 863-869