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Mid-Trimester Endovaginal Sonography in Women at High Risk for Spontaneous Preterm Birth
John Owen, MD;
Nicole Yost, MD;
Vincenzo Berghella, MD;
Elizabeth Thom, PhD;
Melissa Swain, RN;
Gary A. Dildy III, MD;
Menachem Miodovnik, MD;
Oded Langer, MD;
Baha Sibai, MD;
Donald McNellis, MD;
for the National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network
JAMA. 2001;286:1340-1348.
Context Although shortened cervical length has been consistently associated with spontaneous preterm birth, it is not known when in gestation this risk factor becomes apparent.
Objective To determine whether sonographic cervical findings between 16 weeks' and 18 weeks 6 days' gestation predict spontaneous preterm birth and whether serial evaluations up to 23 weeks 6 days' gestation improve prediction in high-risk women.
Design, Setting, and Participants Blinded observational study performed between March 1997 and November 1999 at 9 university-affiliated medical centers in the United States in 183 women with singleton gestations who previously had experienced a spontaneous birth before 32 weeks' gestation.
Observation Certified sonologists performed 590 endovaginal sonographic examinations at 2-week intervals. Cervical length was measured from the external os to the functional internal os along a closed endocervical canal. Funneling and dynamic cervical shortening were also recorded.
Main Outcome Measure Spontaneous preterm birth before 35 weeks' gestation, analyzed by selected cutoff values of cervical length.
Results Forty-eight women (26%) experienced spontaneous preterm birth before 35 weeks' gestation. A cervical length of less than 25 mm at the initial sonographic examination was associated with a relative risk (RR) for spontaneous preterm birth of 3.3 (95% confidence interval [CI], 2.1-5.0; sensitivity = 19%; specificity = 98%; positive predictive value = 75%). After controlling for cervical length, neither funneling (P = .24) nor dynamic shortening (P = .054) were significant independent predictors of spontaneous preterm birth. However, using the shortest ever observed cervical length on serial evaluations, after any dynamic shortening, the RR of a cervical length of less than 25 mm for spontaneous preterm birth increased to 4.5 (95% CI, 2.7-7.6; sensitivity = 69%; specificity = 80%; positive predictive value = 55%). Compared with a single cervical measurement at 16 weeks' to 18 weeks 6 days' gestation, serial measurements at up to 23 weeks 6 days significantly improved the prediction of spontaneous preterm birth in a receiver operating characteristic curve analysis (P = .03).
Conclusions Cervical length assessed by endovaginal sonography between 16 weeks' and 18 weeks 6 days' gestation, augmented by serial evaluations, predicts spontaneous preterm birth before 35 weeks' gestation in high-risk women.
Author Affiliations: Department of Obstetrics and Gynecology, University of Alabama at Birmingham (Dr Owen); Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas (Dr Yost); Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pa (Dr Berghella); George Washington University Biostatistics Center, Bethesda, Md (Dr Thom); Department of Obstetrics and Gynecology, Wake Forest University, Winston-Salem, NC (Ms Swain); Department of Obstetrics and Gynecology, University of Utah, Salt Lake City (Dr Dildy); Department of Obstetrics and Gynecology, University of Cincinnati, Ohio (Dr Miodovnik); Department of Obstetrics and Gynecology, University of Texas, San Antonio (Dr Langer); Department of Obstetrics and Gynecology, University of Tennessee, Memphis (Dr Sibai); and the National Institute of Child Health and Human Development, Bethesda, Md (Dr McNellis). Dr Dildy is now with the Louisiana State University, Baton Rouge; Drs Miodovnik and Langer are now with Columbia University, New York City, NY; Dr Sibai is now with the University of Cincinnati, Ohio; and Dr McNellis is retired.
RELATED ARTICLE
September 19, 2001
JAMA. 2001;286(11):1389-1390.
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