Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Perform a cervical length assessment in pregnancy
2. Discuss the timing of cervical length screening or surveillance in pregnancy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from August 7 2018 through August 7 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

SMFM and other professional organizations have released guidance on cervical length (CL) screening for preterm birth (PTB) prevention. The finding of a short cervix, irrespective of obstetric history, has been consistently shown to be associated with higher risk for PTB.

Steps for CL assessment

• Have patient empty bladder
• Acquire the sagittal, long-axis image of entire cervix (75% of screen)
• Confirm that the anterior and posterior cervixes are of equal thickness
• Measure endocervical canal from internal to external os
  • Ensure that internal and external os are seen and canal seen throughout
  • Place calipers at the internal and external os where the anterior and posterior walls of the cervix meet
• If the endocervical canal curves
  • Add linear measurements together to obtain the final cervical length
• Dynamic cervical shortening
  • Exam time 3–5 minutes and/or
  • suprapubic/fundal pressure
• Obtain 3 images for CL determination
  • Use the shortest, best measurement

Note: SMFM does not recommend routine CL surveillance in women with cerclage, multiple gestation, PPROM, or placenta previa (Grade 2B)

Who and When to Screen for CL

Screening in Asymptomatic women

• SMFM
  • Based on evidence, general population screening “cannot yet be universally mandated”
  • For those who wish to screen their patients including low risk, it may be considered ‘reasonable’ with
    • “Strict adherence to guidelines”
    • Measurement between 16 and 24 weeks (Grade 2B)
• SOGC (Canada)
  • Universal screening in Canada can not be mandated at this time and more research is warranted
• ISUOG
  • Insufficient evidence to recommend offering universal screening in the general population
• RANZCOG
  • Cervical length measurement at 18-24 weeks should be “considered”
  • Two step approach of abdominal scan first followed by transvaginal as needed
• FIGO
  • Does recommend measurement in low risk population
  • “Should be performed in all pregnant women at 19–23+6 weeks of gestation using transvaginal ultrasound”
  • Can be done same time as anatomic scan

Surveillance in asymptomatic women with prior sPTB

• SMFM: Every 1 to 2 weeks (depending on clinical status) between 16 and 24 weeks (Grade 1A)

SYNOPSIS:

Two thirds of preterm births are spontaneous, and only 10% of births <34 weeks will occur to women with a history of spontaneous preterm birth (sPTB). Few predictive tests are available for PTB prediction, and mid-trimester CL assessment remains the best clinical tool at identifying high-risk women. Women with short cervix and prior sPTB are at highest risk.

KEY POINTS:

• Current threshold for “short” cervix: Range of 20 to 30 mm
• Transvaginal ultrasound is more sensitive and reproducible that transabdominal ultrasound in detecting cervical shortening
• Sonographers and practitioners should receive specific training in acquisition and interpretation of cervical imaging (Grade 2B)
• Practitioners who implement universal screening should follow strict guidelines (Grade 2B)

Special circumstances

• History of treatment for cervical dysplasia (LEEP, cold-knife cone)
  • CL screening the same as that of asymptomatic women without history of sPTB
• Determining status post-cerclage placement
  • Insufficient data to suggest clinical benefit (Grade 2B)
• Multiple gestations
  • 18% will have short cervix by 22-24 weeks
  • SMFM does not recommend CL surveillance due to lack of effective interventions (Grade 2B)
• Threatened preterm labor (PTL)
  • CL measurement may be used as adjunct to digital examination
  • In conjunction with FFN in women with CL of 20-29 mm (‘grey zone’)
    • FFN negative: no treatment
    • FFN positive: corticosteroids and additional interventions
  • PPROM
    • Insufficient data to suggest clinical benefit (Grade 2B)
  • Placenta previa
    • Insufficient data to suggest clinical benefit (Grade 2B)

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Learn More – Primary Sources:

SMFM Consult Series #40: The role of routine cervical length screening in selected high-and low-risk women for preterm birth prevention

AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers

Fetal Medicine Foundation Cervical Length Assessment Program

SOGC: Universal Cervical Length Screening

FIGO: Best Practices in Maternal Fetal Medicine 

ISUOG: How to Measure Cervical Length

Related ObG Topics:

Does fetal fibronectin testing prevent preterm birth?

Does Shortened Midtrimester Cervical Length Predict Preterm Birth?

Does Vaginal Progesterone Improve Birth Outcomes for Mothers with Short Cervix?

Cervical Cerclage – Professional Recommendations