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Ultraschall Med 2024; 45(02): 190-198
DOI: 10.1055/a-2091-7179
Original Article

Prediction of Preterm Birth with the Uterocervical Angle in Singleton Pregnancies Treated with a Cervical Pessary

Prädiktion der Frühgeburt mittels des uterozervikalen Winkels bei Einlingsschwangerschaften unter Pessartherapie
Ioannis Kyvernitakis
1   Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
,
Friederike von Gehren
1   Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
,
Marcel Malan
1   Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
,
Ahmet Baschat
2   Gynecology & Obstetrics, Johns Hopkins University, Baltimore, United States
,
Holger Maul
1   Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
,
Maciej Osinski 
1   Asklepios Clinic Barmbek, Departament of Obstetrics and Prenatal Medicine, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
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Abstract

Background Cervical pessaries are an established therapy option for patients at risk for spontaneous preterm birth (sPTB). The uterocervical angle (UCA) remains a promising sPTB predictor. However, its clinical significance has yet to be described in patients treated with a pessary.

Methods This study analyzed data of patients treated with a pessary because of cervical shortening in singleton pregnancies. The patients were divided into 2 groups according to transvaginal ultrasound findings: the funneling group (n = 68) and the no-funneling group (n = 42). Moreover, we analyzed patients within these prespecified groups according to the UCA < 95° and ≥ 95°.

Results Delivery occurred significantly earlier in patients treated with a pessary and with a high UCA ≥ 95°(p = 0.006). The median gestational age at delivery in patients treated with a pessary and with no funneling and a UCA < 95° vs. ≥ 95° were 39.00 and 36.14 weeks, respectively (p = 0.005). In cases with funneling and a UCA < 95° vs. ≥ 95° the mean gestational age at delivery was 38.14 and 38.07 weeks respectively (p=1,00). There was a significant negative linear correlation between UCA and the gestational age at delivery in all patients (p = 0.04), which was even profound in the group without funneling (p = 0.0002). However, we found no significant correlation between cervical length and gestational age at delivery in all patients (p = 0.42) as well as in the group without funneling (p = 0.28).

Conclusion In spite of pessary treatment, patients with UCA ≥ 95° presented with a higher risk of sPTB compared to patients with UCA < 95°. This suggests that the UCA seems to be a better predictor of sPTB than the cervical length in patients receiving pessary treatment.

Zusammenfassung

Hintergrund Das zervikale Pessar ist eine etablierte Therapieoption für Patientinnen mit Frühgeburtsrisiko. Der uterozervikale Winkel (UCA) ist eine vielversprechende Screeningmethode zur Einschätzung des Frühgeburtsrisikos. Dennoch ist seine klinische Bedeutung bei Patientinnen unter Pessartherapie noch nicht untersucht worden.

Methoden In dieser Studie wurden die Daten von Patientinnen mit Einlingsschwangerschaften, welche mit einem Pessar wegen Zervixverkürzung behandelt wurden, analysiert. Die Patientinnen wurden nach dem transvaginalen Ultraschallbefund in 2 Gruppen eingeteilt: in die Gruppe mit Trichterbildung (n = 68) und die Gruppe ohne Trichterbildung (n = 42). Außerdem wurden die Patientinnen anhand des UCA < 95° und ≥ 95° untersucht.

Ergebnisse Die Entbindung erfolgte in der Gruppe ohne Trichterbildung signifikant früher bei Patientinnen unter Pessartherapie und mit einem UCA ≥ 95° (p = 0,006). Die Medianwerte der Schwangerschaftsdauer unter Pessar mit UCA < 95° und ≥ 95° waren 39,00 und 36,14 Wochen respektive (p = 0,005). In Fällen mit Trichterbildung und einem UCA < 95° vs. ≥ 95° war die Schwangerschaftsdauer 38.14 und 38.07 Wochen respektive (p=1,00). Es bestand eine signifikante negative lineare Korrelation zwischen dem UCA und der Schwangerschaftsdauer bei allen Patientinnen (p = 0,04) und eine noch stärkere Korrelation in der Gruppe ohne Trichter (p = 0,0002). Wir fanden jedoch keine signifikante Korrelation zwischen der Zervixlänge und der Schwangerschaftsdauer (p = 0,42).

Schlussfolgerungen Trotz einer Pessartherapie wiesen Patientinnen mit einem UCA ≥ 95° ein höheres Risiko für eine Frühgeburt im Vergleich zu Patientinnen mit einem UCA < 95° auf. Diese Ergebnisse legen nahe, dass der UCA bei Patientinnen unter Pessartherapie ein besserer sonografischer Prädiktor für eine Frühgeburt als die Zervixlänge zu sein scheint.

Keywords

Cervical Pessary - Uterocervical Angle - Cervical Length - Preterm Birth

Supplementary Material



Publication History

Received: 08 May 2022

Accepted after revision: 11 May 2023

Accepted Manuscript online:
11 May 2023

Article published online:
08 December 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 WHO. recommended definitions, terminology and format for statistical tables related to the perinatal period and use of a new certificate for cause of perinatal deaths. Modifications recommended by FIGO as amended October 14, 1976. Acta Obstet Gynecol Scand 1977; 56: 247-253 (PMID: 560099)
    Google Scholar
  • 2 Berger R, Abele H, Bahlmann F. et al. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) – Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes. Geburtshilfe Frauenheilkd 2019; 79: 813-833
    Google Scholar
  • 3 Abdel-Aleem H, Shaaban OM, Abdel-Aleem MA. Cervical pessary for preventing preterm birth. Cochrane Database Syst Rev 2013; 2013 (05) CD007873 DOI: 10.1002/14651858.CD007873.pub3. (PMID: 23728668)
    Google Scholar
  • 4 Goldenberg RL, Culhane JF, Iams JD. et al. Epidemiology and causes of preterm birth. Lancet 2008; 371: 75-84 DOI: 10.1016/S0140-6736(08)60074-4. (PMID: 18177778)
    Google Scholar
  • 5 Liu L, Oza S, Hogan D. et al. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016; 388: 3027-3035
    Google Scholar
  • 6 Liu L, Oza S, Hogan D. et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015; 385: 430-440
    Google Scholar
  • 7 Delnord M, Blondel B, Zeitlin J. What contributes to disparities in the preterm birth rate in European countries?. Curr Opin Obstet Gynecol 2015; 27: 133-142 DOI: 10.1097/GCO.0000000000000156. (PMID: 25692506)
    Google Scholar
  • 8 Vink J, Yu V, Dahal S. et al. Extracellular Matrix Rigidity Modulates Human Cervical Smooth Muscle Contractility-New Insights into Premature Cervical Failure and Spontaneous Preterm Birth. Reprod Sci 2021; 28: 237-251
    Google Scholar
  • 9 Kyvernitakis I, Berger R, Maul H. Letter to the Editor: FIGO good practice recommendations on the use of pessary for reducing the frequency and improving outcomes of preterm birth. Int J Gynaecol Obstet 2022; 157: 216-217 DOI: 10.1002/ijgo.14099. (PMID: 35128647)
    Google Scholar
  • 10 Kyvernitakis I, Maul H, Bahlmann F. Controversies about the Secondary Prevention of Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2018; 78: 585-595 DOI: 10.1055/a-0611-5337. (PMID: 29962517)
    Google Scholar
  • 11 Guerby P, Girard M, Marcoux G. et al. Midtrimester Cervical Length in Low-Risk Nulliparous Women for the Prediction of Spontaneous Preterm Birth: Should We Consider a New Definition of Short Cervix?. Am J Perinatol 2021; 38 (12) 1303-1307
    Google Scholar
  • 12 Bamber J, Cosgrove D, Dietrich CF. et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology. Ultraschall Med 2013; 34: 169-184 DOI: 10.1055/s-0033-1335205. (PMID: 23558397)
    Google Scholar
  • 13 Kyvernitakis I, Maul H, Rath W. et al. Position Paper of the Task Force for Obstetrics and Prenatal Medicine (AGG – Section Preterm Birth) on the Placement, Removal and Surveillance of the Arabin Cervical Pessary in Patients at Risk for Spontaneous Preterm Birth. Geburtshilfe Frauenheilkd 2019; 79: 1171-1175 DOI: 10.1055/a-1007-8613. (PMID: 31736505)
    Google Scholar
  • 14 Souka AP, Papastefanou I, Michalitsi V. et al. A predictive model of short cervix at 20–24 weeks using first-trimester cervical length measurement and maternal history. Prenat Diagn 2011; 31: 202-206 DOI: 10.1002/pd.2683. (PMID: 21268041)
    Google Scholar
  • 15 Berger R, Abele H, Bahlmann F. et al. Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) – Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes. Z Geburtshilfe Neonatol 2019; 223: 373-394
    Google Scholar
  • 16 Saccone G, Maruotti GM, Giudicepietro A. et al. Effect of Cervical Pessary on Spontaneous Preterm Birth in Women with Singleton Pregnancies and Short Cervical Length: A Randomized Clinical Trial. JAMA 2017; 318: 2317-2324
    Google Scholar
  • 17 Ream MA, Lehwald L. Neurologic Consequences of Preterm Birth. Curr Neurol Neurosci Rep 2018; 18: 48 DOI: 10.1007/s11910-018-0862-2.. (PMID: 29907917)
    Google Scholar
  • 18 Salomon LJ, Diaz-Garcia C, Bernard JP. et al. Reference range for cervical length throughout pregnancy: non-parametric LMS-based model applied to a large sample. Ultrasound Obstet Gynecol 2009; 33: 459-464 DOI: 10.1002/uog.6332. (PMID: 19277949)
    Google Scholar
  • 19 Berghella V, Saccone G. Cervical assessment by ultrasound for preventing preterm delivery. Cochrane Database Syst Rev 2019; 9: CD007235 DOI: 10.1002/14651858.CD007235.pub4. (PMID: 31553800)
    Google Scholar
  • 20 The Fetal Medicine Foundation. Cervical assessment. Accessed January 29, 2023 at: https://fetalmedicine.org/
    Google Scholar
  • 21 Kagan KO, Sonek J. How to measure cervical length. Ultrasound Obstet Gynecol 2015; 45: 358-362 DOI: 10.1002/uog.14742. (PMID: 25632014)
    Google Scholar
  • 22 Dziadosz M, Bennett T-A, Dolin C. et al. Uterocervical angle: a novel ultrasound screening tool to predict spontaneous preterm birth. Am J Obstet Gynecol 2016; 215: 376.e1-376.e7
    Google Scholar
  • 23 Farràs Llobet A, Higueras T, Calero IZ. et al. Prospective evaluation of the uterocervical angle as a predictor of spontaneous preterm birth. Acta Obstet Gynecol Scand 2020; 99: 1511-1518
    Google Scholar
  • 24 Luechathananon S, Songthamwat M, Chaiyarach S. Uterocervical Angle and Cervical Length as a Tool to Predict Preterm Birth in Threatened Preterm Labor. Int J Womens Health 2021; 13: 153-159 DOI: 10.2147/IJWH.S283132. (PMID: 33568951)
    Google Scholar
  • 25 Barbone AS, Li X, Arabin B. et al. Preliminary modeling of effective positioning of Arabin cerclage pessary in women at high risk of preterm birth. Ultrasound Obstet Gynecol 2020; 55: 557-558 DOI: 10.1002/uog.20375. (PMID: 31237035)
    Google Scholar
  • 26 Cannie MM, Dobrescu O, Gucciardo L. et al. Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study. Ultrasound Obstet Gynecol 2013; 42: 426-433 DOI: 10.1002/uog.12507. (PMID: 23671013)
    Google Scholar
  • 27 Arabin B, Alfirevic Z. Cervical pessaries for prevention of spontaneous preterm birth: past, present and future. Ultrasound Obstet Gynecol 2013; 42: 390-399 DOI: 10.1002/uog.12540. (PMID: 23775862)
    Google Scholar
  • 28 Meijer-Hoogeveen M, Roos C, Arabin B. et al. Transvaginal ultrasound measurement of cervical length in the supine and upright positions versus Bishop score in predicting successful induction of labor at term. Ultrasound Obstet Gynecol 2009; 33: 213-220 DOI: 10.1002/uog.6219. (PMID: 19173229)
    Google Scholar
  • 29 Khamees RE, Khattab BM, Elshahat AM. et al. Uterocervical angle versus cervical length in the prediction of spontaneous preterm birth in singleton pregnancy. Int J Gynaecol Obstet 2022; 156: 304-308 DOI: 10.1002/ijgo.13629. (PMID: 33507541)
    Google Scholar
  • 30 Knight JC, Tenbrink E, Onslow M. et al. Uterocervical Angle Measurement Improves Prediction of Preterm Birth in Twin Gestation. Am J Perinatol 2018; 35: 648-654 DOI: 10.1055/s-0037-1608877. (PMID: 29190844)
    Google Scholar