Donald School Journal of Ultrasound in Obstetrics and Gynecology

Register      Login

VOLUME 17 , ISSUE 4 ( October-December, 2023 ) > List of Articles

Original Article

The Value of Transvaginal Ultrasonography in Management of Preterm Birth in Singletons

Zoran Belics, Zoltán Papp

Keywords : Cervical gland area, Cervix, Funneling, Physical examination, Prematurity, Preterm birth, Preterm delivery, Shortening, Spontaneous preterm birth, Transvaginal ultrasound, Ultrasound

Citation Information : Belics Z, Papp Z. The Value of Transvaginal Ultrasonography in Management of Preterm Birth in Singletons. Donald School J Ultrasound Obstet Gynecol 2023; 17 (4):332-340.

DOI: 10.5005/jp-journals-10009-1997

License: CC BY-NC 4.0

Published Online: 28-12-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Prematurity, which occurs in about 12% of pregnancies worldwide, continues to be one of the leading causes of perinatal morbidity and mortality worldwide. Preterm birth (PTB) can still be considered a syndrome with a variety of causes and underlying factors, which results in mostly unnoticed contraction of the uterus and changes in the cervix. Despite considerable effort aimed at decreasing the incidence of spontaneous PTB, PTB remains the leading cause of perinatal morbidity and mortality. In light of the available data, screening strategies for PTB are deficient. Approaches used to identify women considered by historical factors to be low risk for preterm delivery, as well as those at high risk for PTB, continue to evolve. Ultrasound evaluation of the cervix during pregnancy has been the focus of much research during the past decades. Cervical measurement by transvaginal sonography (TVS) has been shown to be a good predictive test for spontaneous PTB in high- and low-risk singleton pregnancy. Cervical shortening, which is often detected on ultrasound examination before it can be appreciated on physical examination, is one of the first steps in the processes leading to labor and can precede labor by several weeks. This is likewise true for funneling and loss of cervical gland area, which cannot be assessed with the physical examination. Therefore, all of these markers, especially if they are used together, can be useful to predict PTB and start adequate therapy as soon as possible to prevent spontaneous preterm delivery.

  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. Acta Obstet Gynecol Scand 1977;56(3):247–253. PMID: 560099.
  2. Romero R, Dey SK, Fisher SJ. Preterm labor: one syndrome, many causes. Science 2014;345(6198):760–765. DOI: 10.1126/science.1251816
  3. Blencowe H, Cousens S, Chou D, et al. Born too soon: the global epidemiology of 15 million preterm births. Reprod Health 2013;10(Suppl 1):S2. DOI: 10.1186/1742-4755-10-S1-S2
  4. Rodrigues T, Rocha L, Barros H. Physical abuse during pregnancy and preterm delivery. Am J Obstet Gynecol 2008;198(2):171–176. DOI: 10.1016/j.ajog.2007.05.015
  5. Caughey AB. Definition, incidence, significance and demographic characteristics of preterm birth. UpToDate; 2007. Available at: Accessed December 17, 2007.
  6. Lockwood CJ. Overview of preterm labor and delivery. UpToDate 2007. Available at: Accessed December 17, 2007.
  7. Robinson JN, Norwitz E. Risk factors for preterm labor and delivery. UpToDate 2017. Available at:. Accessed Jun 02, 2017.
  8. Crane JM, Delaney T, Hutchens D. Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia. Obstet Gynecol 2006;107(1):37–44. DOI: 10.1097/01.AOG.0000192169.44775.76
  9. Arbyn M, Kyrgiou M, Simoens C, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008;337:a1284. DOI: 10.1136/bmj.a1284
  10. Jolley JA, Wing DA. Pregnancy management after cervical surgery. Curr Opin Obstet Gynecol 2008;20(6):528–533. DOI: 10.1097/GCO.0b013e328317a411
  11. Dasanayake AP, Gennaro S, Hendricks-Munoz KD, et al. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33(1):45–49. DOI: 10.1097/01.NMC.0000305657.24613.47
  12. Yudin MH, Money DM, Infectious Diseases Committee. Screening and management of bacterial vaginosis in pregnancy. J Obstet Gynaecol Can 2008;30(8):702–716. DOI: 10.1016/S1701-2163(16)32919-X
  13. Viswanathan M, Siega-Riz AM, Moos MK, et al. Outcomes of maternal weight gain. Evid Rep Technol Assess (Full Rep) 2008;168:1–223. PMID: 18620471.
  14. 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(9):567–573. DOI: 10.1056/NEJM199602293340904
  15. Owen J, Yost N, Berghella V, et al. Can shortened midtrimester cervical length predict very early spontaneous preterm birth? Am J Obstet Gynecol 2004;191(1):298–303. DOI: 10.1016/j.ajog.2003.11.025
  16. Alexander S, Boulvain M, Ceysens G, et al. Repeat digital cervical assessment in pregnancy for identifying women at risk of preterm labour. Cochrane Database Syst Rev 2010;6:CD005940. DOI: 10.1002/14651858.CD005940.pub2
  17. 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. DOI: 10.3109/14767058.2012.657278
  18. Kagan KO, Sonek J. How to measure cervical length. Obstet Gynecol 2015;45(3):358–362. DOI: 10.1002/uog.14742
  19. 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(4):863–869. DOI: 10.1097/01.AOG.0000258276.64005.ce
  20. Owen J, Yost N, Berghella V, et al. Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth. JAMA 2001;286(11):1340–1348. DOI: 10.1001/jama.286.11.1340
  21. Iams JD, Johnson FF, Sonek J, et al. Cervical competence as a continuum: a study of ultrasonographic cervical length and obstetric performance. Am J Obstet Gynecol 1995;172(4 Pt 1):1097–1103. DOI: 10.1016/0002-9378(95)91469-2
  22. Hibbard JU, Tart M, Moawad AH. Cervical length at 16-22 weeks’ gestation and risk for preterm delivery. Obstet Gynecol 2000;96(6):972–978. DOI: 10.1016/s0029-7844(00)01074-7
  23. 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):54 e1-88. DOI: 10.1016/j.ajog.2009.12.005
  24. 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. DOI: 10.1002/uog.8911
  25. Heath VC, Southall TR, Souka AP, et al. Cervical length at 23 weeks of gestation: relation to demographic characteristics and previous obstetric history. Ultrasound Obstet Gynecol 1998;12(5):304–311. DOI: 10.1046/j.1469-0705.1998.12050304.x
  26. Greco E, Gupta R, Syngelaki A, et al. First-trimester screening for spontaneous preterm delivery with maternal characteristics and cervical length. Fetal Diagn Ther 2012;31(3):154–161. DOI: 10.1159/000335686
  27. To MS, Skentou C, Cicero S, et al. Cervical assessment at the routine 23-weeks’ scan: problems with transabdominal sonography. Ultrasound Obstet Gynecol 2000;15(4):292–296. DOI: 10.1046/j.1469-0705.2000.00094.x
  28. Ludmir J. Sonographic detection of cervical incompetence. Clin Obstet Gynecol 1988;31(1):101–109. DOI: 10.1097/00003081-198803000-00012
  29. Conde-Agudelo A, Romero R. Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol 2015;213(6):789–801. DOI: 10.1016/j.ajog.2015.06.015
  30. 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. DOI: 10.1016/j.ajog.2009.08.015
  31. Figo Working Group on Best Practice in Maternal-fetal MedicineInternational Federation of Gynecology and Obstetrics. Best practice in maternal-fetal medicine. Int J Gynaecol Obstet 2015;128(1):80–82. DOI: 10.1016/j.ijgo.2014.10.011
  32. Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. JAMA 2017;317(10):1047–1056. DOI: 10.1001/jama.2017.1373
  33. Iams JD, Goldenberg RL, Mercer BM, et al. The preterm prediction study: can low-risk women destined for spontaneous preterm birth be identified? Am J Obstet Gynecol 2001;184(4):652–655. DOI: 10.1067/mob.2001.111248
  34. Berghella V, Baxter JK, Hendrix NW. Cervical assessment by ultrasound for preventing preterm delivery. Cochrane Database Syst Rev 2013;2013(1):CD007235. DOI: 10.1002/14651858.CD007235.pub3
  35. Mella MT, Berghella V. Prediction of preterm birth: cervical sonography. Semin Perinatol 2009;33(5):317–324. DOI: 10.1053/j.semperi.2009.06.007
  36. Miller ES, Tita AT, Grobman WA. Second-trimester cervical length screening among asymptomatic women: an evaluation of risk-based strategies. Obstet Gynecol 2015;126(1):61–66. DOI: 10.1097/AOG.0000000000000864
  37. Kushnir O, Izquierdo LA, Smith JF, et al. Transvaginal sonographic measurement of cervical length. Evaluation of twin pregnancies. J Reprod Med 1995;40(5):380–382. PMID: 7608880.
  38. Wennerholm UB, Holm B, Mattsby-Baltzer I, et al. Fetal fibronectin, endotoxin, bacterial vaginosis and cervical length as predictors of preterm birth and neonatal morbidity in twin pregnancies. Br J Obstet Gynaecol 1997;104(12):1398–1404. DOI: 10.1111/j.1471-0528.1997.tb11010.x
  39. Guzman ER, Walters C, O'reilly-Green C, et al. Use of cervical ultrasonography in prediction of spontaneous preterm birth in triplet gestations. Am J Obstet Gynecol 2000;183:1108–1113. DOI: 10.1067/mob.2000.108875
  40. Goldenberg RL, Iams JD, Miodovnik M, et al. The preterm prediction study: risk factors in twin gestations. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol 1996;175(4 Pt 1):1047–1053. DOI: 10.1016/s0002-9378(96)80051-2
  41. Michaels WH, Montgomery C, Karo J, et al. Ultrasound differentiation of the competent from the incompetent cervix: prevention of preterm delivery. Am J Obstet Gynecol 1986;154(3):537–546. DOI: 10.1016/0002-9378(86)90598-3
  42. Varma TR, Patel RH, Pillai U. Ultrasound assessment of the cervix in ‘at risk’ patients. Acta Obstet Gynecol Scand 1986;65(2):147–152. DOI: 10.3109/00016348609158370
  43. Bartolucci L, Hill WC, Katz M, et al. Ultrasonographyin preterm labor. Am J Obstet Gynecol 1984;149(1):52–56. DOI: 10.1016/0002-9378(84)90291-6
  44. Zilianti M, Azuaga A, Calderon F, et al. Monitoring the effacement of the uterine cervix by transperineal sonography: a new perspective. J Ultrasound Med 1995;14(10):719–724. DOI: 10.7863/jum.1995.14.10.719
  45. Sekiya T, Ishihara K, Yoshimatsu K, et al. Detection rate of the cervical gland area during pregnancy by transvaginal sonography in the assessment of cervical maturation. Ultrasound Obstet Gynecol 1998;12(5):328–333. DOI: 10.1046/j.1469-0705.1998.12050328.x
  46. Savitha C, Arpitha JV, Nagarathnamma R. Significance of cervical length and cervical gland area in cervical maturation. Int J Reprod Contracept Obstet Gynecol 2016;5(8):2634–2639. DOI: 10.18203/2320-1770.ijrcog20162635
  47. Asakura H, Fukami T, Kurashina R, et al. Significance of cervical gland area in predicting preterm delivery birth for patients with the threatened preterm delivery: comparison with cervical length and fetal fibronectin. Gynecol Obstet Invest 2009;68(1):1–8. DOI: 10.1159/000209394
  48. Espinoza J, Goncalves LF, Romero R, et al. The prevalence and clinical significance of amniotic fluid ‘sludge’ in patients with preterm labor and intact membranes. Ultrasound Obstet Gynecol 2005;25(4):346–352. DOI: 10.1002/uog.1871
  49. Kusanovic JP, Espinoza J, Romero R, et al. Clinical significance of the presence of amniotic fluid ‘sludge’ in asymptomatic high-risk patients for spontaneous preterm delivery. Ultrasound Obstet Gynecol 2007;30(5):706–714. DOI: 10.1002/uog.4081
  50. Kovacevich GJ, Gaich SA, Lavin JP, et al. The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes. Am J Obstet Gynecol 2000;182(5):1089–1092. DOI: 10.1067/mob.2000.105405
  51. Abdul Sultan A, West J, Tata LJ, et al. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England. BMJ 2013;7(347):f6099. DOI: 10.1136/bmj.f6099
  52. Convertino VA, Bloomfield SA, Greenleaf JE. An overview of the issues: physiological effects of bed rest and restricted physical activity. Med Sci Sports Exerc 1997;29(2):187–190. DOI: 10.1097/00005768-199702000-00004
  53. Teede HJ, Bailey C, Moran LJ, et al. Association of antenatal diet and physical activity-based interventions with gestational weight gain and pregnancy outcomes: a systematic review and meta-analysis. JAMA Intern Med 2022;182(2):106–114. DOI: 10.1001/jamainternmed.2021.6373
  54. 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(2):161–180. DOI: 10.1016/j.ajog.2017.11.576
  55. Romero R, Conde-Agudelo A, Rehal A, et al. Vaginal progesterone for the prevention of preterm birth and adverse perinatal outcomes in twin gestations with a short cervix: an updated individual patient data meta-analysis. Ultrasound Obstet Gynecol 2022;59(2):263–266. DOI: 10.1002/uog.24839
  56. Fonseca EB, Celik E, Parra M, et al. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007;357(5):462–469. DOI: 10.1056/NEJMoa067815
  57. Romero R, Nicolaides KH, Conde-Agudelo A, et al. Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. Ultrasound Obstet Gynecol 2016;48(3):308–317. DOI: 10.1002/uog.15953
  58. ACOG Practice Advisory. Updated Clinical Guidance for the Use of Progesterone Supplementation for the Prevention of Recurrent Preterm. Birth. April 2023 (Accessed on April 10, 2023).
  59. Norwitz ER, Progesterone supplementation to reduce the risk of spontaneous preterm labor and birth. UpToDate; 2023. Available at: Accessed Jun 23, 2023.
  60. Berghella V, Odibo AO, To MS, et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol 2005;106(1):181–189. DOI: 10.1097/01.AOG.0000168435.17200.53
  61. Enakpene CA, DiGiovanni L, Jones TN, et al. Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening. Am J Obstet Gynecol 2018;219(4):397.e1–397.e10. DOI: 10.1016/j.ajog.2018.06.020
  62. Souka AP, Papamihail M, Pilalis A. Very short cervix in low-risk asymptomatic singleton pregnancies: Outcome according to treatment and cervical length at diagnosis. Acta Obstet Gynecol Scand 2020;99(11):1469–1475. DOI: 10.1111/aogs.13881
  63. Gulersen M, Bornstein E, Domney A, et al. Cerclage in singleton gestations with an extremely short cervix (≤10 mm) and no history of spontaneous preterm birth. Am J Obstet Gynecol MFM 2021;3(5):100430. DOI: 10.1016/j.ajogmf.2021.100430
  64. Coutinho CM, Sotiriadis A, Odibo A, et al. ISUOG Practice Guidelines: role of ultrasound in the prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2022;60(3):435–456. DOI: 10.1002/uog.26020
  65. Berghella V, Lockwood CJ. Cervical insufficiency. UpToDate; 2023. Available at: Accessed April 11, 2023.
  66. Belics Z, Papp Z. Ultrasonographic assessment of the cervix for prediction of spontaneous preterm birth in singleton pregnancies. Donald School J Ultrasound Obstet Gynecol 2021;15(1):49–63. DOI: 10.5005/jp-journals-10009-1683
  67. Berghella V, Bega G, Tolosa JE, et al. Ultrasound assessment of the cervix. Clin Obstet Gynecol 2003;46(4):947–962. DOI: 10.1097/00003081-200312000-00026
  68. 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. DOI: 10.1016/j.ajog.2012.10.877
  69. Orzechowski KM, Boelig R, Nicholas SS, et al. Is universal cervical length screening indicated in women with prior term birth? Am J Obstet Gynecol 2015;212(2):234.e1–234.e5. DOI: 10.1016/j.ajog.2014.08.029
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.