Sonography of the Cervix - SD

Introduction to Sonography of the Cervix

Hi, I'm Vincenzo Berg.

I'm professor of Tetris and Gynecology and Director of Maternal Fetal Medicine at Thomas Jefferson University.

I will be talking about sonography of the cervix.

There are now over 1000 papers written about sonography of the cervix, and this is a very hot topic in the literature.

While 15 years ago when I began to study cervical sonography, we were kind of the pioneers in this field.

Now, pretty much every unit in the US and abroad is doing transvaginal ultrasound of the cervix, which can be done many different ways, as you can see from this four d real time display.

Again, I want to thank everybody at Thomas Jeffers University, especially in the division of Maternal Field Medicine, for their support As the data that I will show you, it's really a part of a team effort from everybody back in Philadelphia.

The outline of the talk will be a review of the techniques as we are in a sonography course, but I would also emphasize the clinical use of this sonographic procedure, especially as it relates to preterm birth, its prediction and prevention, and then symptomatic women with preterm labor and P prom.

And I will also explore some use of cervical sonography at term.

Techniques of Cervical Sonography

First of all, I wanna make sure you all understand that, that when we talk about cervical sonography, we do not talk about transabdominal sonography, but we talk about transvaginal sonography when we first started looking at the cervix.

We use transabdominal ultrasound, but there are many shortcomings to this procedure, as you can see in the slides.

My point is that no clinical decision should be based on transabdominal ultrasound alone.

We should not use transabdominal ultrasound, probably even for screening, because many times we miss a cervix that it's wide, shortened, or open by transvaginal ultrasound.

So please, if you really want a screen for preterm birth with trans, with, cervical ultrasound, don't use transabdominal trans labial could be used, but unfortunately also has shortcomings, especially the fact that the external oz, as you can see in the slides, it's difficult to see and it's, so, it's more difficult to obtain an adequate image than the standard, which is transvaginal ultrasound.

The technique of transvaginal ultrasound, the way I like to, the acronym is TVU.

You can also use TVUS, which is trust your vaginal ultrasound, TYUS, sorry.

Again, it's been around for a while and it's really revolutionized OB GYN in general.

As you can see in this slide, the, bladder needs to be empty.

The procedure is safe, comfortable, and well accepted by patients, and it's certainly easier than even trans labial so that since you have the probe so close to the cervix and you get the best image, the technique of transvaginal ultrasound is the gold standard.

The technique is very important, and I want to review it in detail.

Again, once again, before you take the patient into the room, you make sure that she empties air bladder, use a condom cover probe.

We usually let the patient insert such a probe, and as you can see, the probe goes into anura fornix of the cervix, and then you obtain a view of the all length of the endo cervical canal.

As you can see in this picture, as I am pointing here, is the internal o here's the external O.

You wanna make sure you don't put too much pressure on the cervix.

You'll large the image as much as you can, at least two thirds of the screen, if not more.

And then you obtain multiple measurements.

In the literature, it did say that you should obtain at least three, use the shortest best measurement that gets a view of the whole cervix, and then repeat those three measurements.

After you apply transoral pressure for a few seconds, the total exam should last at least five minutes, because over such time, you may detect not only changes after pressure, but also spontaneous changes.

You wanna make sure you standardize this technique and you do it the same all the time.

That Ventura lip of the cervix is similar to the posterior lip of the cervix that you see, the whole endo cervical canal.

And that, again, there is no increased echogenicity.

That is the technique, but why do we do transvaginal ultrasound?

We do transvaginal sound, mostly at this point to predict preterm birth, which incident has been increased tremendously, at least 30% in the last 20, 25 years, and is now 12.7% in the us, which is over half a million.

Over 500,000 births every in the US are delivered before 37 weeks, and about 2% below 32 weeks.

Transvaginal diss, not cervix, has been shown to be really the most predictive test for preterm birth, because the cervix when it's gonna open begins to open at the internal, a finding that you cannot detect on manual exam.

Prediction of Preterm Birth Using Transvaginal Ultrasound

So we're gonna review how well transvaal cell predicts preterm birth, looking at a comparison to manual exam, what you're gonna measure, what is normal or or abnormal, when to do it, what kind of clinical scenarios you're gonna look at.

And its utility.

We do know from a study now done 12 years ago and replicated multiple times.

Then as you can see, on the left part of the slide, cervical length by manual exam does predict preterm delivery, but cervical length measured in the same patients by transvaginal ultrasound as a much higher probability of detecting preterm delivery, a much higher area under the curve and a much more significant p value.

You can take multiple measurements on trans transvaginal ultrasound as again, you can see in the slide, but cervical length, or the close part of the cervix, even if there is a little bit of opening den internal s is what you wanna measure.

So the distance from the external s to the end of the closed part of the endocervical mucosa, as you can see here, the measurement in a normal long cervix is an inch to two.

And when you're measuring a short cervix, again, you don't wanna measure the all length of the cervix, but you wanna measure the length of the cervix that is staying and closed, as we used to call it, the functional length.

You can also mention in a report the opening year funneling, we most reported as B over A plus B in terms of measurements in the slides, but that's really doesn't add much to the prediction.

And here you can see it in the slides funneling in terms of degree of funneling is related to a higher and higher incidence of preterm birth, but it's also subjective, as you can see in this slide, really hard to tell what their internal loss was.

That really cervical length is the accepted gold standard.

We do know, though, that the few patients that have a normal cervical length, but have significant founding have increased or an increased an indeed an increased risk of return birth.

Sometimes you see cervixes that are closed, and what are you gonna measure?

You could measure o to o so to speak, but usually when the distance between the cervix and this imaginary direct line is more than five millimeters, we prefer to take two measurements and add those two measurements together.

Again, when you have a curd cervix, that usually means that it's a long cervix.

If you have a short cervix, it's almost always gonna be straight, and so the fact that you say a curd cervix shouldn't make you worry too much, but it's actually a reassuring finding.

In terms of preterm birth.

Pitfalls in Transvaginal Ultrasound Measurement

There's several pitfalls.

The transvaginal ultrasound is not a perfect technique.

I want to, I want, again, you wanna make sure that you avoid some of these technical and anatomic pitfalls.

As you can see in these old slides, we used to not be too attentive to empty the bladder, and it's very important to empty the bladder.

These bladders are too full and may mask some funneling as probably it's happening on this case, on the right of the slide.

So again, you wanna make sure that the bladder is completely empty, and if there is any fluid in the bladder, it is a little bit of a slit there, and the cervix appears to be in its natural state.

You don't wanna put too much pressure in the probe, and you can see that by the fact that here, there is the echogenicity of anterior lip, it's excessive, theor lip is too white, so to speak, and it's also much thinner than the non compressed posterior lip at the cervix.

You also wanna make sure you see the all cervix and you place the calipers in a good position.

I really don't know.

And review from this case many years ago, again, over a decade ago, what the sonographer was measuring.

You wanna take the whole cervix.

I wanna make sure you know where the external and internal os are and where the new internal os after funneling.

Yes, again, it's very difficult to place calipers when you have funneling, and that's why measuring this remaining functional closed cervix here is most helpful.

When you see a contraction again, that may mask ing or unmask ing depending on the case.

And again, you don't wanna take this kind of measurements as shown here in the calipers, but you want to just take the functional cervical length.

Sometimes there can be a local contractions.

You can see here extra genicity in this part of the cervix and this slicer from at Guzman.

And if you wait long enough fusion, this contractions over time resolves.

And sometimes, as you can see here, funneling can be amassed.

And the remaining cervical length here, this measurement of the closed cervix is less than a centimeter.

So this lady is very high risk for pum birth.

Here's another example of a contraction up in the lower urine segment, but the remaining cervix loss, okay?

And sometimes you see a contraction that makes the cervix very curved.

Again, you have to wait, make sure the bladder is empty, and then remeasure the cervix later on.

So the best measurement, again to emphasize is cervical length.

As it is the most reproducible and most predictive, dynamic changes can occur and improve the predictive accuracy.

Therefore, when you see those record, the best, shortest and cervical length here is a study of over 700 high risk women that we followed.

The Jefferson, as you can see, between about 14 weeks to about 28 weeks.

The cervical length is about the same in most studies, about 35 to 40 millimeters in average before 12 weeks.

Very hard to distinguish the lower urine segment from the through cervical length.

So we do not recommend doing cervical ultrasound for prediction of return birth before 14 weeks, and also after 20 weeks, the cervix begins to shorten any way, and even in patients that deliver a term.

And therefore, cervical ultrasound is not recommended after 20 weeks for the prediction of preterm birth as a screening test.

Again, cervical ultrasound is not a diagnosis text, but as a screening test, transvaginal ultrasound does really well because it, that is an important condition as we've seen.

It's a well-described techniques, which again, we have reviewed.

It's safe, acceptable, very reliable, and reproducible recognizes an early asymptomatic phase, as I've showed you, and it's accurate in its prediction.

And now there is finally some treatments that can be effective in prevention, which I'll review in detail to put transvaginal ultrasound in its clinical application.

Again, there's many papers that review the fact that it's a safe procedures, even in patients with premature preterm rupture membrane with a randomized study by Dr. Carlin in 97, and it is acceptable by over 99% of women who would have it again in the future.

It is reliable heir.

I wanna make a comparison to NAL translucency.

I think just like NAL translucency and other ultrasound measurements, you have to make sure that you've done a number of practice transvaginal cervix that was reviewed and checked for quality, and you have to make sure that you have a quality assurance program for your transvaginal standard cervix.

Once you do that, inter observer and inter observer variability are very acceptable.

Here's a 3D multiple planner display.

Again, you can use certainly 3D for cervical ultrasound, but it's really not been shown to be very helpful except for getting nice pictures here for lectures.

As you can see here, these pictures are over 10 years old, and they're beautiful pictures of the cervix in the three different planes.

Here is an ultrasound showing significant funneling and even some sludge, significant amount of sludge at the bottom of the cervix.

This woman has a cervix that it's only now one or two millimeters, and the presence of sludge means inflammation.

Her risk could deliver in perturb.

It's over 90 percent at this point.

Here's a picture of a woman with a circlage, which is the usual sagittal view in the upper right, with the two spots of the circlage.

You can see here that on the different 3D view, the axial view, you can see the whole suture.

Here is another nice 3D that depicts the fact that on the coronal view, you can really tell what the true endo cervical canal axis is and get the most accurate cervical length view.

Again, this difference from regular to the ultrasound, it's only one to two millimeters most of the time, and so it's probably not clinically important, but certainly may be important in the future for future research efforts using that image of the whole circlage around the endocervical canal.

We'll talk a lot about circlage in the few Next few slides.

These a live 3D four D view again, of the cervix.

The lady that had the funneling, we placed a c collage high in their uterus, and as you can see, is keeping the cervix closed at least lower two centimeters.

And it's straight around the end the cervical canal and keeping it closed, even if, as you can see here, membranes are trying to bulge down, and you can see some sludge as well.

Here's a picture of a cerclage that has not worked.

A lot of the times, clinicians don't anchor it too well to the posterior part of the cervix, and the cerclage can slip.

And obviously in this situation, as it is only in the anterior lipid cervix, you won't be very efficacious for predicting and preventing preterm birth.

So, normal cervical length when you should measure it, which is between 14 and 28 to 30 weeks, is about 25 to 50 millimeters, as I showed you, is it is not alpha before 14 weeks.

And if it is less than 25 millimeters or less than an inch before, between 14 and 24 weeks, that is abnormal.

And as you can see in this classic graph where Dr. Iams the shorter the cervical length is, the higher is incidence of preterm birth.

And again, the number that you get from the cervical length is very predictive of when the woman is gonna deliver.

It's also important though, not to just look at the number, the cervical length number in millimeters.

So it's also important to look at many other factors, one of which is when you get it, if you get, for example, cervical length measurements of 10 millimeters at 16 weeks, the risk may be up to almost 60% for delivering pre 50 to 60%, while if you get the same measurements a week, 28 when it's almost physiologic to begin to shorten.

But since the shortening is significant, the lady still has a risk, but the risk is less than 40% of delivering preterm.

So very important to put it in perspective with gestational age.

When should you do it?

If you do just one screening for preterm birth in a low risk patients, I will recommend to do it around 18 to 22 weeks because that's the meantime in which the cervix shortens women best interpret to deliver preterm.

Obviously, if you do it more often, the prediction is higher, but possibly that more frequent screening should really be only in populations at high risk of preterm birth, such as those with prior preterm birth, in which often we do screening every two weeks between 16 and 24 weeks.

And it's also important to look at outcomes.

Outcomes are related to the populations you studied, and all of these populations have been studied now in multiple studies in terms of prediction of preterm birth with transvaginal cervical length.

And all of the studies have reported that transvaal cervical length is predictive of preterm birth in all the population.

Singleton are high or low risk for preterm birth with different high risk factors, multiple gestation to instant triplets, and also symptomatic women with preterm labor or P prom.

This is a classic slide from the best blinded studies of transvaginal ultrasound.

So these women did not have intervention, and you can follow the natural, his history of screening for, with transvaginal cervical length, they're all used a cutoff of 25 millimeters, which is pretty much the one most used in clinical practice.

Now they screen in the second trimester between 16 and 24 weeks, and they looked at preterm birth in less than 35 weeks.

As you can see, the sensitivity is actually quite low in low risk women and highest in high risk women with a proper term birth.

And also the positive predictive value is much higher in this high risk women with a positive, with a per preterm birth.

So really as a test, transvaginal ultrasound won't do too well in low risk.

Women with a low background aary incidence of preterm birth, will do best in singleton with a proper term birth or somehow kind of other high risk factors, and won't do that well either in twins, because again, while the positive predictive value is high because of a high instance of preterm birth, the sensitivity is very low, probably because twins have opening of the cervix only after Stretching and maybe even some asymptomatic contractions of the uterus.

And they're not really a risk for cervical insufficiency.

Their cervix is fine, and that's why looking at it won't help too much in predicting preterm birth.

Improving Outcomes: Preventive Interventions

I just wanna switch gears a little bit and talk about not necessarily this book, but how we in medicine can make things better and how we can perform better and improve our outcomes.

So we ask a questions, we count and study our outcomes.

We write them up in literature, and we eventually change practice without complaining too much about working day and night.

So once we decided and discovered that transvaginal sano the cervix was predictive, we have to understand why the cervix is opening, and then we have to study what can we do to change?

Because being predictive, it's not enough.

It's not gonna help us in terms of helping the woman avoid a catastrophic preterm birth.

There are many hypothesis as to why the cervix is shortening or opening, but the leading ones are that it's just not working.

You know, somehow the collagen fibers are more interspersed.

The ma matric has changed, and that happens a lot because of surgery, because of some kind of surgery to the cervix as you see there, or because of some kind of prior pattern birth or second trimester loss.

I discussed the fact that uterine distension may be the cause for the cervix opening in multiple gestation, or in cases which the uterus is extra distended.

Obviously, contractions can open the cervix or infection can be related to cervical shortening.

Based on those hypothesis, we have come up with preventive interventions to try to avoid a preterm birth, which we are now predicting by the shortening of the cervix and ultrasound.

And again, this last part of the lecture, I will review mostly the clinical application, cervical length, which is looking at intervention to prevent its outcome.

Cerclage for Short Cervix

And first I will review cerclage, which has been the one by far most and best study pleasing a stitch around the cervix to keep it closed when we see that it's opening.

First of all, there are many benefits of ultrasound screening, especially in average patients before, and I have certainly a lot of data from the eighties and nineties, a lot of patients with a proper term birth, and especially a second trimester loss.

We used to play, we used to place a cyclage anyway at the beginning of the pregnancy.

Now we can actually follow with ultrasound.

And the vast majority of these women, over 60% of women with a proper term birth, actually maintain the cervix.

Look looking like this one on the slide, nice and long and closed, more than 25 millimeters.

And of these women, less than 10% of deliver preterm, very few do, and therefore, no intervention is needed.

So first, do no arm cervical ultrasound has really helped us decrease the incidence of cervical circlage.

In our unit at Jefferson, we used to have about 3% incidence of circlage in our population, it is now less than 1%, and it is because of cervical ultrasound, the policy of not placing any certain indicated circlage versus following them.

But ultrasound and placing a circlage, only if the cervix shorten has been studied in at least four randomized studies.

Four randomized studies here listed.

You can see the number of patients, the outcomes that we're looking at.

And again, this women all had risk factors for preterm birth, and neither had all of them a circlage at 12 weeks or so, or were followed by ultrasound and circlage only in the minority of cases in which the cervix shorten.

As you can see, none of the single studies had significant differences between these two practice par patterns.

And when we put them all together, again, the meta-analysis showed no difference.

So, very safe to follow somebody at high risk for preterm birth with ultrasound sound.

But what do we do with the interesting patient that have a short cervix?

Again, cerclage has been the procedure more studied, and there are at least five randomized studies now that have been published.

The last one has been published only in abstract form, and I'll review it different separately.

The first four are summarized in this meta-analysis that we published in 2005.

The authors of the single randomized studies were US at Jefferson, Dr. Alia High Valley, Dr. Tuus in Oland, and DR to in the UK and many other countries around the world.

When we looked at the 200 and some patients that had single gestation, a prior preterm birth, and a short cervix, the ones that had circlage here in yellow had a much lower incidence of preterm birth, 11 than 35 weeks compared to the ones that were just followed and didn't have circlage.

The relative risk was 0.61.

And as you can see, the conference interval did not cross one.

So that this was a significant results by placing the this 107 CI lodges and the randomized study, we saved five neonates.

So the number needed to treat was one in 21.

Here is looking at now the most recent study yet unpublished, but presented as Society for Maternal fetal medicine a couple months ago.

And Dr. Owen and colleagues, including as at Jefferson, randomized, now 300 women.

So even more than all the four prior studies combined with similar criteria, a singleton gestation, a proper term birth than there were followed in the second trimester.

And the one that had a short cervix were randomized to circlage or non circlage.

And as you can see, once again, the circlage column is much shorter.

32% rate of preterm birth versus 42% in the non circlage.

And the decrease was about 33 percent in preterm birth.

They looked at this many different ways with Kaplan Myers and other statistics, and that they did find that this was a significant difference.

When we put the 200 patients from the first four studies and the 300 from the most recent NIH sponsor study, we get 500 plus patients with the same characteristics.

And now the results are even clearer, about 30% incidents with circlage, 40% incidence of preterm birth without circlage, and at 29% decrease in preterm birth.

So you can certainly tell somebody that if you do screening with cervical length because they've had a proper term birth, by placing a cerclage, you can decrease their chance of delivering preterm by 30%.

I think that's level one evidence and is now being well studied and well proven in the literature.

All the studies pointed in the same directions and have a lot of strength been put together.

There's been a lot of controversy saying What is the right cervical length cutoff.

As you can see, these are data from the first four studies.

Circlage seems to work both for the women at the extreme left of the slides with a very short cervix, so less than six millimeters, as well as the women that have a cervix that is minimally short, 21 to 24.9 millimeters.

So a lot of controversy, but again, I think even at this mildly short, so to speak, cervix disease in the second trimester, women with high risk factors such as proper term birth and a mildly short cervix, are gonna benefit from circlage.

The biggest population, though, is gonna be the women without such a history, without significant risk factors and a short cervix anyway.

And as you can see here, there is a trend in the meta-analysis for a decrease in preterm birth from 33 in controls to 26% in the ultrasound indicated circlage.

But the results are not yet significant, and I think that this issue is being understudied in twins instead, cerclage seems to be detrimental, and we have therefore stopped doing cervical ultrasounds in multiple gestation because we really don't know what to do with the results.

If we place a cerclage, we actually doubled more than doubled then interpret, return, birth.

And this randomized data, we unfortunately cost ized or ate more neonates compared to controls that indeed have a short cervix, but did not repeat circlage.

So we do not, we have not performed circlage in twin pregnancy in the last three years at Jefferson.

Here is data, looking at the preterm bursal left 32 weeks.

And again, our most interesting data sets of singleton with a proper term birth and a short cervix.

And again, it seems to work to decrease this most terrible and full of bad consequences cutoff for preterm birth.

So what is our management in 2000 and and nine?

Our management is that in singleton gestations, if they have multiple proper in birth, at least three or more, and especially if they were second trimester losses, we will place a history indicated cyclage two weeks.

And if they do it again, if they have another loss place, a transabdominal clash.

There are very, very few women on this arm nowadays.

Very, very few women, we can count them on our hands almost at Jefferson.

Most of the women are only gonna have one or two proper term, birth of second trimester losses, and they can all, so over 90% of these high risk women be followed with transvaginal ultrasound.

And if the cerv shortens, now we feel comfortable.

We don't have to enroll them anymore in randomized studies that really we ran for almost a decade, and we can offer them a cerclage, which will prevent their preterm birth by about 30%.

Other Interventions: Antibiotics and Progesterone

What else can we do?

We've studied antibiotics for short cervix, and so far antibiotics have not been shown to prevent a preterm birth in this women.

And we've also studied progesterone.

There's different kinds of progesterones, as you can see in the slides, and especially the first two natural progesterone.

And 17 p.

This is 17 p hydroxy progesterone cap rate have been studied to prevent preterm ery in women with short cervix.

Most of the studies are women with a proper term birth, once again without looking at the cervix.

And it's now, I think, well proven by Dr. Mes trial, Paul, me, as you can see in the slide and others, that 17 hydroxy progesterone is efficacious in preventive, preterm birth, and women with a proper term birth.

And this practice is supported by the American College of O-B-G-Y-N in terms of vaginal progesterone.

The results are controversial as there is one negative and one positive trial.

But what we're interested in here in this talk is what to do when we have a short cervix.

The biggest trial looking at the efficacy of progesterone came from Dr. Dca, a Brazilian working with Dr. Nickis in London, who ran them, who actually followed over 24,000 women, low risk women, of which approximately 250, develop a short cervix, a very short cervix of 50 millimeters or less in the second trimester.

At that point, they were randomized to either get progesterone 200 milligrams of progesterone weekly, once a cervical length was shown to be short or at identical placebo.

And as you can see in this important New England journal of Medicine study, the differences was marked, 19% only incidence of preterm birth, less than 34 weeks versus 44% in control.

Again, a 44% decrease in preterm birth.

Very, very impressive results.

Unfortunately, this results really come from just the studied, and again, when you look at the Kaplan Mire, you can see that the progesterone women did much better and stayed pregnant much longer compared to placebos.

That is really the best.

And only study looking, just the progesterone.

There are other interventions that have been postulated to help.

PEs is one of them, unfortunately, no randomized studies on the use of pessary for short cervix have been published yet.

And the good news is there are many randomized studies currently going on.

Diagnosis and Management of Preterm Labor

The next thing I wanna talk about is the diagnosis and management of preterm labor.

This is how we used to do it in the past and still now in ma in many units.

Lady comes in, she has pain, and you put her on the monitor.

She has contractions.

You look at her cervix, and it looks short by manual exam.

It's kind of a blinded procedure, awkward, and very subjective in a practitioner to practitioner, that's the old way to do a diagnosis of preterm labor.

I think that the new way should be using the transvaginal probe.

Now, we have a lot of information that using the transvaginal probe is much better at diagnosis, preterm labor.

There are many studies now almost 20 studies looking at cervical length in the third trimester.

Now all of these studies show that transvaginal sin is predictive, preterm birth in women that have symptoms upper preterm labor.

And really this study showed that the cervix is less than 30 millimeters, and there's a high chance, high positive predictive value that you'll deliver preterm.

While if the cervix is nice and long, especially 30 more than 30 millimeters, the chances of liver and peri are usually three, four, 5%, 10 at most.

And if your cervix even is more than 15 millimeters, so a little bit short, but not too much the chance of deliver within a week, which is really what clinicians wanna know, it's minuscule.

Our review now one randomized study that we did here at Jefferson, and it's really the only one using cervical length and overacting for prevention of preterm birth in when women preterm labor.

We had a hundred women that presented with preterm labor between 24 and three, three weeks.

All of them were screened with fetal fing first and then transvaginal ultrasound, but on only 50% of them.

We had knowledge of this information, and on 50% the pharmacy and the sonographer didn't tell us.

The results of this two screening tests on the knowledge group, we followed this algorithm.

If the cervix was again, 30 millimeters or more, we actually would send 'em home, even if they were contracting or if the cervix was delayed manually.

If the cervix was shorter than 20 millimeters, we use, again, cervical length only to treat usually with steroids and with lysis omitted them in the delivery room.

If the cervix was borderline 22, 29 millimeters, field of fib decided what to do.

If it was positive, we treated them aggressively as those with a shorter cervix.

If it was negative, we watched them a little bit more, but basically, most of them we would send home.

It's interesting that in this study, many other similar studies, not looking at intervention, but just looking at outcomes, about 50% or more of women that come in with preterm labor have a long cervix of 30 millimeters and really deserve no interventions and deserve reassurance.

In this randomized studies, when we compare the knowledge group in which we use transvaginal cervical length for management, the incidence ofum birth was only 13%.

These women were well managed apparently, and in the control groups in which we were blinded to that information, the instance was 36 percent.

This showed 65 decrease in preterm birth, less than 37 weeks, very significant.

Unfortunately, this study is not replicated yet, but certainly seems to point in the right directions in terms of management of women with preterm labor.

And as you can see here in the green line on this couple of mire, the survival curve, so to speak, was much shifted to the right, and women that were managed with cervical antifa had much longer gestations.

Why would cervical anti feal be beneficial?

First of all, because we avoid intervention and women that don't need it.

And as you know, intervention time sometimes can cause return birth focus interventions on the women that truly need it, especially the ones that have cervix less than 20 millimeters.

And there is some data to show that tocolytic, steroids, et cetera, are much more effective in those women.

Obviously, as I say, this randomized control trial needs to be repeated.

We also wrote recently a Cochrane review, which is was published this week online by the Cochran Review.

If you have it and look at it, feel free to go and check it out.

We put together our studies with two other studies that looked at fetal fing.

And when we looked at this results, again, they seem to be some benefit from using fetal f acting in vaginal women with preterm labor, especially driven by our study in which this was used with cervical length.

Conclusion

So in conclusion, transvaginal ultrasound, cervical length predicts preterm birth in any population.

You're gonna study in very predictive, as predictive as field FB acting.

And more predictive than any other test used.

More importantly, it can be used for prevention of preterm birth, because if you find a singleton, especially one with a proper term birth, or cervix is long, you can avoid intervention.

While if the cervix is short in second trimester, you can place a ultrasound indicated cyclage, and that will prevent upper term birth by about 30%.

Also, if the cervix is very short, you can consider vaginal progesterone.

Again, this came only from one randomized study, but was shown to be very efficacious.

There's still not enough information on endo medicine, bed rest, peary, and other interventions.

And another important piece of news in the last couple years is that in symptomatic women, not only transvaginal ultrasound is predictive, but it helps to prevent preterm birth and treat the women that most need it.

With that, I want to thank you for your attention.

We cover a lot of ground, and I hope you now have a good idea of the benefits of transvaginal ultrasound for clinical use by radiologists and obstetricians worldwide.

Thank you.