Transvaginal ultrasound in pregnancy: its acceptability to women and maternal psychological morbidity

Preterm Birth: Screening and Prediction

Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.

A cross-sectional survey of women's views and preferences for preterm birth screening and treatment

OBJECTIVES

Primary outcomes were to determine; 1) the desire for more patient information from healthcare professionals on preterm birth (PTB) prevention 2) the desire for PTB screening surveillance or participation in research or 3) the acceptability of transvaginal ultrasound (TVUS) or vaginal examinations to predict spontaneous PTB.

METHODS

A 19-question, piloted, self-administered survey was completed by unselected pregnant women in a tertiary maternity hospital in Dublin, Ireland. Data was collected to include maternal socio-demographics, past obstetric history, and current pregnancy details, in addition to views and preferences on PTB screening and preventative treatments. Statistical analysis to include binary and multinomial regression was performed by IBM SPSS Statistics for Windows (Version 29.0).

RESULTS

277 women completed the study survey. 9.4% of women had attended the preterm birth surveillance clinic (PSC). 75.1% of respondents indicated a preference for more information from healthcare professionals about PTB. 65% reported that TVUS and vaginal examinations were acceptable in pregnancy. The acceptability of antenatal examinations was significantly influenced by ethnicity; white European (OR 2.58, CI 1.12-5.95, p = 0.003) and Asian (OR 3.39, CI 1.18-9.67, p = 0.02). Discomfort (25.3%) and vaginal bleeding (11.9%) were the most frequently reported concerns about TVUS. 95.7% of unselected women indicated that they would accept treatment to prevent PTB. Vaginal progesterone (53.8%) was preferred treatment compared to cervical cerclage (15.9%) or cervical pessary (16.6%). 55.6% of respondents stated they attend or wish to attend for additional appointments or research opportunities for PTB screening. Women with a previous PTB or second trimester miscarriage were more likely to attend or wish to attend for PTB screening (OR 3.23, CI 1.34-7.79, p = 0.009).

CONCLUSION

PTB is an important healthcare priority for pregnant women in Ireland. However, women require more information, counselling and reassurance about the utility and safety of TVUS in PSCs.

Exploring the lived experiences of debilitating period pain management in the UK

Background

Five to ten percent of women experience period pains that disrupt their lives yet 4 in 5 women believe that their claims for their dysmenorrhea are not taken seriously. Within the process of seeking support and understanding about their pain, they face various barriers that prevent them from finding the answers they deserve.

Methods

Semi-structured interviews were conducted with 8 women aged 20-28 to discuss their experiences with dysmenorrhea throughout their time since menarche.

Results

Using Scheper-Hughes and Lock understanding of the mindful body, this research explores women's experiences of dysmenorrhea through their physical body (relationship with the body and needing control), the social body (cultural concepts and comparisons to others) and the body politic (medicalisation, the medical team and the transvaginal ultrasound).

Conclusions

The impact of these aspects of their mindful bodies developed arguments showing how different actors had an impact on preventing them obtaining the patient-centred care they required without resistance. More must be done to honour the experience of pain women have regarding their periods, especially by healthcare professionals. There must be consistency in the way women are approached for their dysmenorrhea to prevent discrepancies of support. This must be done with clearer guidance on what is offered to women with dysmenorrhea, especially in the primary care setting.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part two - translation into practice

Introduction

A lack of patient safety research hampers capacity to improve safety in healthcare.Ultrasound is often considered 'safe' as it does not use ionising radiation, a simplistic view of patient safety. Understanding sonographers' actions towards patient safety is crucial; however, self-reported measures cannot always predict behaviour. This study is part of a PhD exploring patient safety in medical diagnostic ultrasound. The aim of this paper is to explore sonographers' responses to the patient safety concerns identified in Part one of this study. The ultimate aim of the study is to inform the final phase of the doctoral study which will consider the next steps in improving the quality and safety of healthcare experienced by patients.

Methods

A qualitative study using semi-structured, one-on-one interviews. The Theory of Planned Behaviour (TPB) explained how sonographers respond to perceived patient safety risks in practice.

Results

Thirty-one sonographers were interviewed. Based on the seven themes identified in Part one of the study, results showed that incongruences exist between identifying patient safety risks and the actions taken in practice to manage these risks.

Conclusion

The TPB showed that behavioural, normative and control beliefs impact sonographers' responses to perceived patient safety risks in practice and can lead to risk avoidance. Lack of regulation in ultrasound creates a challenge in dealing with Fitness to Practice issues. Collective actions are required to support sonographers in taking appropriate actions to enhance patient safety from multiple stakeholders including accreditation bodies, regulatory authorities, educational institutions and employers.

The acceptability of cervical electrical impedance spectroscopy within a multi-modal preterm birth screening package: a mixed methods study

BACKGROUND

Reducing the rate of preterm birth is a cornerstone of global efforts to address child mortality, however existing screening tests offer imperfect prediction. Cervical electrical impedance spectroscopy (EIS) is a novel technique to quantify the ripening changes which precede labour. Mid-trimester EIS measurements have been shown to accurately predict preterm birth in asymptomatic women. This study aimed to comprehensively evaluate the acceptability of cervical EIS to low and high-risk women as part of a package of screening tests performed during a larger prospective trial.

METHODS

In this parallel convergent mixed methods study, 40 women completed questionnaires before and after screening tests (EIS, cervical length measurement and fetal fibronectin quantification). Quantitative outcomes were anxiety levels before and after screening (Spielberger State Trait Anxiety Inventory, STAI-6), pain (Short Form McGill Pain Questionnaire) and ratings of EIS device appearance and test acceptability (visual analogue scales). Twenty-one women (11 high-risk, 10 low-risk) also attended a semi-structured qualitative interview. Interviews were recorded and transcribed, then thematic analysis was performed. A convergence coding matrix was constructed to enable triangulation of quantitative and qualitative results.

RESULTS

High risk women demonstrated a significant reduction in anxiety following screening (mean STAI-6 score 34.5 vs. 29.0, p = 0.002). A similar trend was observed among low-risk participants. Ratings of pain, EIS device appearance and procedural acceptability did not differ between groups. Mean pain ratings were low (visual analogue scale 0.97 and 1.01), comparing favourably to published evaluations of conventional screening tests. Qualitative analysis provided insight into both the physical consequences and emotional experiences of screening. Additional determinants of the screening experience included device design, pre-existing perspectives on intimate examination, attitudes to knowledge in pregnancy and interaction with clinical staff. Finally, a range of practical considerations regarding wider use of EIS were identified, with valuable complementary detail regarding acceptability for use in antenatal care.

CONCLUSIONS

Cervical EIS is well tolerated and acceptable to both low and high-risk women when performed as part of a multi-modal screening package. These results provide useful insights to inform the design of future study and screening protocols.

Dangers in the dark: Calling for a safer practice of transvaginal ultrasonography

Background

The intimate examination is an important component of the assessment of a patient presenting with obstetric or gynaecological concerns. Ultrasound practitioners, like any other medical practitioner, are in a unique and privileged position. During the examination, the sonographers engage in a very close and personal interaction with an individual whom they have likely never met. They are also most likely unfamiliar with their social situation, cultural background, previous experiences with the healthcare profession and more importantly, any history of sexual trauma. It is an extremely sensitive area of practice which places a great deal of responsibility on the clinician to ensure that they not only protect their patient from psychological distress, but also themselves, from the threat of litigation arising from such distress.

Aims

This paper highlights the current governance requirements for sonographers and makes suggestions to support them in safeguarding their patients and themselves from allegations of unprofessional conduct, until such a regulatory body exists.

Materials and Methods

A wide-ranging review of the literature exploring the perceptions of female patients regarding intimate sonographic examination was performed using standard search engines. Additionally, grey literature was searched for policy statements and government regulatory documents for guidance on the topic.

Results

Although much research has been undertaken in this field across diverse cultures and knowledge in this area is ever increasing; however, the guidelines for sonographers appear to be site specific and variable. At present, there is no overarching governance for sonographers, as there is with practitioners registered with the Australian Health Practitioner Regulation Agency.

Discussion

While there are practice standards for the purposes of Medicare set out by the Diagnostic Imaging Accreditation Scheme, there is no regulatory professional standard that sonographers are held accountable to. This is problematic and has the potential for inadvertent boundary transgression by the practitioner, as there is also no existing framework for management of such incidents in an equitable manner.

Conclusion

The intimate examination is generally well tolerated; however, there is a subset of the population who are vulnerable to psychological distress arising from the examination. The sonographer must be astute to signs of distress and act in accordance with the intimate examination guidelines set out by AHPRA, for the dual purpose of protecting their patients against harm and also themselves from the threat of litigation.

Utility of follow-up cervical length screening in low-risk women with a cervical length of 26 to 29 mm

BACKGROUND

In women with a previous preterm birth, a protocol for serial cervical length screening has been studied and recommended for the identification and treatment of a short cervix. Cervical length screening along with vaginal progesterone has been suggested for low-risk women with singleton pregnancies to treat a short cervix and reduce preterm birth. However, specific protocols for single vs serial ultrasound measuring cervical length in this population are not established. Cost-effectiveness of universal cervical length screening depends on the cost of screening; follow-up of borderline measurements can contribute to increased costs with uncertain benefit.

OBJECTIVE

This study aimed to determine the utility of follow-up cervical length screening in otherwise low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm through the assessment of the rate of short cervix (≤25 mm) on follow-up ultrasound and subsequent delivery outcomes.

STUDY DESIGN

This was a 2-year retrospective cohort study at a single urban institution of women with singleton pregnancies with no previous spontaneous preterm birth and an initial transvaginal ultrasound cervical length measurement of 26 to 29 mm identified during universal cervical length screening at time of anatomy ultrasound (18 0/7 to 22 6/7 weeks' gestation). The primary outcome was the rate of short cervix (defined as ≤25 mm on transvaginal ultrasound) on follow-up ultrasound at <24 weeks' gestation. Secondary outcomes included the rate of spontaneous preterm birth (<37 and <34 weeks' gestation).

RESULTS

During the study period, there were 2801 women with singleton pregnancies at 18 0/7 to 22 6/7 weeks' gestation with transvaginal ultrasound cervical length screening at time of anatomy scan. Among those women, 201 had a cervical length of 26 of 29 mm, and 184 (7%) had no previous spontaneous preterm birth and were included in the study. Furthermore, 144 women (78%) had a follow-up cervical length completed before 24 weeks' gestation. The mean follow-up interval was 1.5±0.6 weeks. Overall, the percentage of short cervix (≤25 mm) on follow-up was 15% (n=21). Baseline characteristics were similar, but the initial cervical length measurement was shorter in women who subsequently developed a short cervix (26.7±0.8 vs 27.8±1.0; P<.01). Delivery outcomes were available for 126 patients. The rate of spontaneous preterm birth at <37 weeks' gestation in women with an initial cervical length 26 to 29 mm and subsequent short cervix was significantly higher than the rate of spontaneous preterm birth in a historical cohort of low risk women with an initial cervical length >25 mm (16% vs 3%; P=.03). The rate of spontaneous preterm birth at <34 weeks' gestation in women with a subsequent short cervix was 11% (2 of 19).

CONCLUSION

Here, approximately 15% of low-risk women with singleton pregnancies with a midtrimester cervical length measurement of 26 to 29 mm will experience cervical shortening of ≤25 mm before 24 weeks' gestation. Compared to women with singleton pregnancies without a history of preterm birth, the rate of spontaneous preterm birth (16%) in women with an initial cervical length of 26 to 29 mm and a subsequent cervical shortening of ≤25 mm is significantly higher. A total of 111 follow-up ultrasounds measuring cervical length would be required to prevent 1 early preterm birth at <34 weeks' gestation.

The perceptions of pregnant women about cervical length screening for preterm birth prevention

BACKGROUND

The Western Australian Preterm Birth Prevention Initiative was officially launched in November 2014. It demonstrated an initial decrease in the preterm birth rate in Western Australia. One of the key points of this initiative is the routine ultrasound measurement of the cervical length in mid-pregnancy.

AIM

The aim of this study was to evaluate the perceptions and attitudes of Western Australian women regarding transvaginal cervical length (TVCL) screening for preterm birth prevention.

MATERIALS AND METHODS

Self-administered questionnaires were completed by pregnant women before and after their mid-trimester obstetric ultrasound. Maternal demographical and medical data were collected in addition to opinions of TVCL screening.

RESULTS

A total of 598 women participated with the maternal age range representative of the Western Australian obstetric population. There was a high rate of acceptance of TVCL imaging, with 2% of the 149 women declining a transvaginal ultrasound (TVU) offered in this study, 1.5% refusing a TVU in the past and 5.7% reporting that they would have a concern in having a TVU in the future. Women stated that they either had declined TVCL in the past (11%) or would decline in the future (30.7%) as they wanted to discuss the procedure with their clinician first, had been advised not to have a TVU by their clinician (11% in the past and 47.7% in the future) or felt uncomfortable with the operator (22% at a previous TVU and 34.4% in the future).

CONCLUSION

Pregnant women participating in this study had a high acceptance of TVCL screening for preterm birth prevention.

Effects of simulation for gynaecological ultrasound scan training: a systematic review

Introduction

Simulation is a potentially promising solution to some of the challenges in delivering ultrasound training, and in the last decade, research in simulation-based education has rapidly expanded. There have been no prior focused systematic reviews on the effects of simulation on gynaecological ultrasound scan training. The aim of this review was to summarise and critically appraise the available evidence.

Methods

Medline, EMBASE, CINHAL, BNI, PubMed, ERIC, Cochrane Library and ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were studies of all types that investigated the use of a simulator to teach gynaecological ultrasound. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes were classified according to the Kirkpatrick hierarchy and included: patient-related outcomes, such as discomfort; organisational efficiency outcomes, such as examination times; and trainee-related outcomes, such as competence, skill and confidence.

Results

Fourteen studies with 573 participants were included: seven randomised controlled trials, three controlled observational studies and four uncontrolled observational studies. The use of simulation practice in gynaecological ultrasound in addition to standard approaches for teaching is associated with significant improvements in competence, skill and confidence of trainees and reduced patient discomfort, increased perceived patient safety and enhanced confidence in the trainee.

Conclusion

Our findings suggest that simulation in the early stages of training in gynaecological ultrasound is beneficial for the trainee, patients and has organisational benefits through reduced examinations times and need for supervision. Future research needs to confirm these findings in the different settings.

Reasons Why Pregnant Women Participate in Ultrasound Research Involving Transvaginal Scans

OBJECTIVES

The aim of this study was to explore the motivations of pregnant women in participating in an ultrasound study and the acceptability of vaginal ultrasound examinations.

METHODS

A prospective sample of 270 women were asked one question: "Can you tell me what motivated you to participate in the study?" The data were then analyzed through a qualitative thematic analysis with an inductive approach. In addition to the thematic analysis, quantification of the data was performed to enhance the qualitative result.

RESULTS

Through the thematic analysis, 5 themes emerged from the responses of the participants: altruism, research, personal experience, personal benefit, and finding out. All responses were relatively short, and some responses included more than one theme.

CONCLUSIONS

Vaginal ultrasound examinations were acceptable to the participants, and pregnant women had many motivations to participate. Regardless of race, ethnicity, or insurance status, the women in our study were altruistic and curious about our research.

A Quality Study to Explore Rationale for Pregnant Women to Decline Transvaginal Cervical Length Screening

OBJECTIVES

To identify patient rationale for pregnant women to decline transvaginal cervical length screening.

METHODS

Survey data from 511 women presenting for second-trimester anatomy and transvaginal cervical length sonography were collected during a 4-month period from September 2016 to January 2017. Each patient completed a medical questionnaire that includes demographic and obstetric history data and a survey to document their acceptance or declination of transvaginal cervical length screening.

RESULTS

Of the 511 women included in the study, 5.9% (n = 30) declined transvaginal cervical length screening. Demographic characteristics and risk factors for prematurity were similar between those who accepted and declined. The sonographer performing the study was significantly associated with declination of transvaginal cervical length screening (P < .001), with 4 of 13 sonographers accounting for 83.3% of all declinations. The most frequently reported reasons for declining the transvaginal cervical length screening were feeling that it was not needed (47%; n = 14) and not feeling prepared for the transvaginal sonography (27%; n = 8).

CONCLUSION

The findings of this study indicate that the sonographer performing transvaginal cervical length screening may be associated with declination. The most common reasons patients cited for declining included not feeling that the study was needed and not feeling prepared for the procedure. Increased sonographer education and sonographer use of a scripted approach when discussing the procedure with patients may improve patient acceptance.

Can Transabdominal Scan Predict a Short Cervix by Transvaginal Scan?

Background. To determine whether transabdominal screening can be used to screen women with short cervix on transvaginal scan. Methods. The study was done between 18 and 20 weeks of gestation. Transabdominal scan was done and cervical length was measured. Transvaginal scan was also done and cervical length was measured. An attempt was made to find out whether transabdominal scan be used to predict a cervical length of 25 mm by transvaginal scan. Results. In our study the cut-off for transabdominal scan for detecting a short cervix of 25 mm by transvaginal scan was 29 mm. A transabdominal cervical length of 29 mm could predict a short cervix of 25 mm by transvaginal scan by 100% sensitivity and 92.4% sensitivity. Conclusion. A cut-off of 29 mm by transabdominal scan is very accurate in predicting a short cervix of 25 mm by transvaginal scan.

Total uterine artery blood volume flow rate in nulliparous women is associated with birth weight and gestational age at delivery

OBJECTIVES

To investigate the relationship between total uterine artery blood volume flow rate (TVFR) and birth weight and gestational age at delivery, and to establish normal ranges of TVFR throughout pregnancy.

METHODS

This was a prospective cohort study of 334 nulliparous women booking antenatal care at University College London Hospital between August 2008 and September 2009. Women underwent a transabdominal ultrasound examination of uterine arteries for measurement of TVFR at 12, 20 and 24 weeks' gestation. Pregnancy outcomes were recorded and linear regression was used to study the relationship between TVFR and gestational age at delivery and birth weight.

RESULTS

A total of 551 ultrasound scans were performed. There was a significant, positive correlation between TVFR at 11-13 weeks (TVFR1) and at 22-26 weeks (TVFR3) and birth weight. For every 100-mL/min increase in TVFR1 and TVFR3, there was an increase in birth weight of 45 g and 27 g, respectively. There was also a positive association between TVFR1 and gestational age at delivery, with a 1.4-day increase in gestational age for every 100-mL/min increase of TVFR1.

CONCLUSION

Ultrasound measurement of TVFR in the first trimester is significantly associated with both birth weight and gestational age at delivery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Not transabdominal!

Preterm birth remains a major cause of perinatal morbidity and mortality. A short cervix is strongly associated with spontaneous preterm birth. Professional organizations support cervical length screening for singleton gestations with a prior spontaneous preterm birth and second-trimester cervical length measurements between 16-24 weeks. All interventions used to decrease the risk of preterm birth in women with a short cervix are based on clinical trials that used transvaginal cervical length measurement, but transabdominal ultrasound has been shown to correlate well with transvaginal measurement in some observational studies. Transvaginal cervical length measurement is more accurate and more reliably obtained than the transabdominal approach. Conversely, transabdominal ultrasound could have the advantage of ease of implementation and, in general, is perceived by patients to be associated with less discomfort. Currently, there is no randomized clinical study that compares head-to-head the effectiveness of transvaginal vs transabdominal ultrasound for preterm birth risk screening. This point/counterpoint article summarizes the pros and cons of the 2 ultrasound approaches and debates whether transvaginal ultrasound should be used exclusively or if transabdominal ultrasound can be incorporated in cervical length screening for prevention of preterm birth.

Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation

BACKGROUND

Urodynamics (UDS) has been considered the gold standard test for detrusor overactivity (DO) in women with an overactive bladder (OAB). Bladder ultrasonography to measure bladder wall thickness (BWT) is less invasive and has been proposed as an alternative test.

OBJECTIVES

To estimate the reliability, reproducibility, accuracy and acceptability of BWT in women with OAB, measured by ultrasonography, in the diagnosis of DO; to explore the role of UDS and its impact on treatment outcomes; and to conduct an economic evaluation of alternative care pathways.

DESIGN

A cross-sectional test accuracy study.

SETTING

22 UK hospitals.

PARTICIPANTS

687 women with OAB.

METHODS

BWT was measured using transvaginal ultrasonography, and DO was assessed using UDS, which was performed blind to ultrasonographic findings. Intraobserver and interobserver reproducibility were assessed by repeated measurements from scans in 37 and 57 women, respectively, and by repeated scans in 27 women. Sensitivity and specificity were computed at pre-specified thresholds. The smallest real differences detectable of BWT were estimated using one-way analysis of variance. The pain and acceptability of both tests were evaluated by a questionnaire. Patient symptoms were measured before testing and after 6 and 12 months using the International Consultation on Incontinence modular Questionnaire Overactive Bladder (short form) (ICIQ-OAB) questionnaire and a global impression of improvement elicited at 12 months. Interventions and patient outcomes were analysed according to urodynamic diagnoses and BWT measurements. A decision-analytic model compared the cost-effectiveness of care strategies using UDS, ultrasonography or clinical history, estimating the cost per woman successfully treated and the cost per quality-adjusted life-year (QALY).

RESULTS

BWT showed very low sensitivity and specificity at all pre-specified cut-off points, and there was no evidence of discrimination at any threshold (p = 0.25). Extensive sensitivity and subgroup analyses did not alter the interpretation of these findings. The smallest detectable difference in BWT was estimated to be 2 mm. Pain levels following both tests appeared relatively low. The proportion of women who found the test 'totally acceptable' was significantly higher with ultrasonography than UDS (81% vs. 56%; p < 0.001). Overall, subsequent treatment was highly associated with urodynamic diagnosis (p < 0.0001). There was no evidence that BWT had any relationship with the global impression of improvement responses at 20 months (p = 0.4). Bladder ultrasonography was more costly and less effective than the other strategies. The incremental cost-effectiveness ratio (ICER) of basing treatment on the primary clinical presentation compared with UDS was £491,500 per woman successfully treated and £60,200 per QALY. Performing a UDS in those women with a clinical history of mixed urinary incontinence had an ICER of £19,500 per woman successfully treated and £12,700 per QALY compared with the provision of urodynamic to all women. For DO cases detected, UDS was the most cost-effective strategy.

CONCLUSION

There was no evidence that BWT had any relationship with DO, regardless of the cut-off point, nor any relationship to symptoms as measured by the ICIQ-OAB. Bladder ultrasonography has no diagnostic or prognostic value as a test in this condition. Furthermore, despite its greater acceptability, BWT measurement was not sufficiently reliable or reproducible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46820623.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 7. See the NIHR Journals Library website for further project information.

Cervical length screening: a randomized trial assessing the impact on visit length and patient attitudes

OBJECTIVES

The purpose of this study was to quantify the time required for transvaginal cervical length measurements during a second-trimester anatomy scan and to evaluate patient attitudes regarding cervical length assessment.

METHODS

Consenting women were randomly assigned to one of the following: (1) standard arm-cervix visualized, no prespecified cervical length measurement; (2) sequential arm-3 transabdominal cervical length measurements obtained, transvaginal sonography performed if images were inadequate or if any measurement was 3 cm or less; and (3) screening transvaginal sonography arm-3 transvaginal cervical length measurements obtained. Times were recorded for the entire examination and cervical length evaluation. Participants completed a questionnaire at the end of their visits.

RESULTS

Sixty of 230 eligible women enrolled. Demographic characteristics were similar across groups except for body mass index, which was greater in the sequential arm than the screening arm (mean ± SD, 28.5 ± 7.75 versus 24.7 ± 3.89 kg/m(2); P = .03). There were no differences in total examination times between the 3 arms (24.8 ± 8.59 versus 27.8 ± 8.75 versus 28.5 ± 7.78 minutes; P= .39). There were no differences across groups in participant attitudes regarding examination discomfort or embarrassment.

CONCLUSIONS

Performing screening transvaginal sonography to measure cervical length did not have a statistically significant impact on the amount of time for completion of the entire examination. Participants had positive responses regarding cervical length assessment by transabdominal and transvaginal sonography.

Cervical length for predicting preterm birth and a comparison of ultrasonic measurement techniques

Introduction: Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations - the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method. Background: There are three approaches that may be used to perform ultrasound measurements of the cervix; these are the transabdominal (TA), transperineal (TP) and the transvaginal (TV) approach. The TV approach is considered to be the gold standard. In women who are considered to be at a high risk of preterm birth it is now recommended that the cervix is measured at the mid-trimester ultrasound using the TV ultrasound approach. For women considered to be at a historical low risk the TV scan is not recommended, however it has been found that many women who deliver a preterm baby have no known risk factors. Conclusion: There is contradictory evidence in the literature with regard to the correlation between TA, TP and TV measurements. This article provides an overview of these three approaches with a focus on the clinical value for the assessment of the maternal cervix.

Can transabdominal ultrasound identify women at high risk for short cervical length?

OBJECTIVE

To determine whether transabdominal cervical length screening could identify women at high risk for having a short cervix on transvaginal ultrasound.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

POPULATION

A total of 703 patients with a singleton pregnancy at 18 to 23(+6) weeks of gestation who underwent transabdominal and transvaginal cervical length assessment during anatomy ultrasound at a single institution between January 2007 and October 2011.

METHODS

Electronic medical records were reviewed to identify women who met the study criteria.

MAIN OUTCOME MEASURES

The primary outcome was the number of women with a short transabdominal cervical length (defined as ≤ 30 mm) who needed to undergo transvaginal ultrasound to detect one woman with a short transvaginal cervical length of ≤ 20 mm.

RESULTS

In all, 703 patients were included in the primary analysis; 3.42 women with transabdominal cervical length ≤ 30 mm needed to undergo transvaginal ultrasound to detect one woman with transvaginal ultrasound cervical length ≤ 20 mm. Of women with short transvaginal cervical length ≤ 20 mm, 89.8% had a transabdominal measurement ≤ 30 mm and 96.7% had a transabdominal measurement ≤ 33 mm.

CONCLUSIONS

Screening of transabdominal cervical length may represent a useful strategy for detecting women with short cervix on transvaginal ultrasound.

Vaginal progesterone in risk reduction of preterm birth in women with short cervix in the midtrimester of pregnancy

Preterm birth is a major health problem for the neonate, family, country, and society in general. Despite many risk factors being identified for women destined to deliver preterm, short cervical length detected on transvaginal ultrasound is the most plausible, practical and sensitive risk factor for prediction of spontaneous preterm birth. The definition of short cervix has varied in various studies, but most commonly accepted is ≤2.5 cm in the midtrimester of pregnancy, though risk of spontaneous preterm birth (sPTB) increases as the cervical length decreases. Vaginal progesterone, a naturally occurring steroid hormone, is the most bioavailable form of progesterone for uterine and cervical effects with the fewest side effects. Multiple prospective studies have consistently shown its benefits in decreasing sPTB rate in women with asymptomatic midtrimester short cervix. The safety for mother and fetus, and tolerability of vaginal progesterone, particularly the gel form, is also well established. Vaginal progesterone is a minimally invasive intervention that is not painful and is very safe, with reasonable cost where the benefits (even if argued to be small) clearly outweigh the risks. Thus there should be little hesitation for implementation of universal transvaginal cervical length screening and preventive vaginal progesterone treatment for women with short cervix.

Transvaginal ultrasonography: a survey of the acceptability and its predictors among a native African women population

Objective

To determine the acceptability of transvaginal ultrasonography (TVU) and associated factors among Nigerian women.

Method

A cross-sectional survey was conducted among 3137 women who presented for transabdominal ultrasound scan between August and November 2010 in two referral hospitals in Nigeria. Data were obtained using a questionnaire. Descriptive and multivariate analysis was performed applying logistic regression analysis; predictors of willingness of participants regarding transvaginal ultrasound were identified using SPSS Statistics (SPSS Inc, Chicago, IL) version 17 software.

Results

The mean age of the women was 33.8 years (standard deviation = 7.9), with 88.8% currently married. About 84% were willing to have TVU, while 54.2% were indifferent about the gender of the sonologist. About 17.3% believed that the procedure is painful. Significant predictors of willingness to have TVU were previous sexual experience and douching, prior painful vaginal examination, and vaginal surgery.

Conclusion

The majority of Nigerian women expressed a willingness to have the TVU procedure without necessarily opting for any gender preference of the operator. Women should be adequately counseled on the operations of the procedure so as to be able to psychologically prepare for them.

Additional effects of the cervical length measurement in women with preterm contractions: a systematic review

Purpose

Transvaginal cervical length measurement in women with symptoms of preterm labor has been used to decide if treatment is necessary. Cervical length measurement may also have additional effects on patients, such as providing reassurance, although the evidence to support this is unclear. We explored and summarized to what extent additional effects of cervical length measurement in women with threatened preterm labor have been reported in the clinical literature and what the magnitude of these effects was.

Methods

We performed a systematic review of the literature to identify articles reporting on cervical length measurements in women with symptoms of preterm labor. We assessed whether these articles reported patient outcomes other than preterm delivery.

Results

The electronic and hand search resulted in 764 articles, of which 172 met initial criteria for further eligibility assessment. We found 12 articles that reported additional effects of cervical length measurement in symptomatic women, such as the reassurance or the sensory consequences related to the transvaginal procedure. None of the articles quantified such additional effects.

Conclusions

There appears to be a gap between the presumed effects of cervical length measurement on patient outcomes, such as patients’ reassurance, and the actual assessment of these effects during test evaluations. We suggest that future evaluations of prognostic preterm labor tests include a comprehensive assessment of patient outcomes.

Prevention of preterm birth based on short cervix: progesterone

Preterm delivery, which occurs in about 5%-13% of pregnancies in most countries, is the main cause of neonatal morbidity and mortality. Symptomatic treatment of pregnancies presenting in preterm labor with corticosteroids has improved perinatal outcome but has not reduced the incidence of preterm delivery. Recent evidence suggests that the rate of preterm delivery may be reduced by the prophylactic use of progesterone in women with a history of preterm delivery and in those with a short cervical length identified by routine transvaginal sonography. This review summarizes the evidence (level A evidence) of the effectiveness of progesterone on the rate of preterm birth.

Cervical length and obstetric history predict spontaneous preterm birth: development and validation of a model to provide individualized risk assessment

OBJECTIVES

To evaluate the ability of combinations of cervical length and maternal history to assess the risk of spontaneous preterm birth, and to provide a simple procedure for the optimal estimation of risk.

METHODS

This prospective observational study was carried out between January 1998 and May 2006. Transvaginal sonographic measurement of cervical length at 20 + 0 to 24 + 6 weeks of gestation was carried out in 58 807 singleton pregnancies as part of routine antenatal care. The outcome measure was spontaneous extreme (< 28 weeks), early (28-30 weeks), moderate (31-33 weeks) and mild (34-36 weeks) preterm birth. Logistic regression analysis was used to derive models for the prediction of spontaneous preterm birth from the maternal obstetric history, demographic characteristics and cervical length.

RESULTS

The rates of extreme, early, moderate and mild spontaneous preterm birth were 0.23%, 0.24%, 0.57% and 2.93%, respectively. The best prediction of spontaneous preterm birth was provided by cervical length (area under the receiver-operating characteristics curve (AUC), extreme 0.903, early 0.816, moderate 0.784 and mild 0.617) and this was improved by adding obstetric history (AUC, extreme 0.919, early 0.836, moderate 0.819 and mild 0.650). Addition of other parameters was without material effect. For a 10% screen-positive rate, models using cervical length and obstetric history had a sensitivity of 80.6%, 58.5%, 53.0% and 28.6% for extreme, early, moderate and mild spontaneous preterm birth, respectively. These models were expressed as tables of adjusted likelihood ratios to allow simple estimation of the risk of spontaneous preterm birth.

CONCLUSIONS

A model combining cervical length and obstetric history provides a better prediction of spontaneous preterm birth than either factor alone, and the sensitivity of screening improves for increasing degrees of prematurity.

Progesterone and the risk of preterm birth among women with a short cervix

BACKGROUND

Previous randomized trials have shown that progesterone administration in women who previously delivered prematurely reduces the risk of recurrent premature delivery. Asymptomatic women found at midgestation to have a short cervix are at greatly increased risk for spontaneous early preterm delivery, and it is unknown whether progesterone reduces this risk in such women.

METHODS

Cervical length was measured by transvaginal ultrasonography at a median of 22 weeks of gestation (range, 20 to 25) in 24,620 pregnant women seen for routine prenatal care. Cervical length was 15 mm or less in 413 of the women (1.7%), and 250 (60.5%) of these 413 women were randomly assigned to receive vaginal progesterone (200 mg each night) or placebo from 24 to 34 weeks of gestation. The primary outcome was spontaneous delivery before 34 weeks.

RESULTS

Spontaneous delivery before 34 weeks of gestation was less frequent in the progesterone group than in the placebo group (19.2% vs. 34.4%; relative risk, 0.56; 95% confidence interval [CI], 0.36 to 0.86). Progesterone was associated with a nonsignificant reduction in neonatal morbidity (8.1% vs. 13.8%; relative risk, 0.59; 95% CI, 0.26 to 1.25; P=0.17). There were no serious adverse events associated with the use of progesterone.

CONCLUSIONS

In women with a short cervix, treatment with progesterone reduces the rate of spontaneous early preterm delivery. (ClinicalTrials.gov number, NCT00422526 [ClinicalTrials.gov].).

Preterm labour. Cervical function and prematurity

The cervix maintains the fetus in situ during pregnancy and dilates during labour to allow delivery of the baby. Congenital or iatrogenically-induced structural abnormalities of the cervix are associated with an increased risk of preterm birth. The role of cervical infection is less clear. Cervical studies may be useful in the prediction of preterm delivery: both a shortened cervical length identified on transvaginal ultrasound examination and an increased level of fetal fibronectin in cervico-vaginal secretions are associated with an increased risk of preterm delivery. In singleton pregnancy, cervical cerclage reduces the risk of preterm birth by 25%. There is no evidence of a reduction in neonatal mortality or morbidity, and the beneficial effects of preterm birth reduction have to be set against the increased risk of maternal infection. Neither the American College of Obstetricians and Gynecologists (ACOG) nor the Royal College of Obstetricians and Gynaecologists (RCOG) has unequivocally endorsed cervical cerclage. Further work is required to define the role of the cervix in prediction and prevention of spontaneous preterm birth.

PREMATURE CERVICAL CHANGE AND THE USE OF CERVICAL CERCLAGE

Preterm birth and its subsequent consequences continue to be a major challenge worldwide. In the United States in 2004, 12.5% of infants were born preterm, making the annual societal economic burden associated with preterm birth in excess of $26.2 billion (and this is a modest estimate). Spontaneous preterm birth accounts for about 75% of all preterm births; however, at earlier gestations iatrogenic preterm birth accounts for a greater proportion of all preterm births; at 27–28 weeks 50% are iatrogenic. The proportion of babies transferred to the neonatal unit is more than 90% for those born before 33 completed weeks of gestation compared with 31% at 36 weeks; delivery between 33 completed weeks and 36 completed weeks has a relatively low morbidity and mortality. Nonetheless, 1 in 3 children born preterm but beyond 32 weeks have educational and behavioural problems at the age of 7, with 1 in 4 children born between 32 and 35 weeks requiring support from non-teaching assistants at school. Although more than 40% of babies at 35 completed weeks show signs of maturity, some still need ventilation at 38 completed weeks. Almost one-fifth of all infants born at less than 32 weeks gestation do not survive the first year of life.

Ultrasound assessment of the endometrium for irregular vaginal bleeding

Irregular vaginal bleeding is a common symptom of women seeking gynecologic care. Etiologies of irregular vaginal bleeding can be classified into the following categories: pregnancy related (retained products of conception, threatened or missed abortion, or ectopic pregnancy), hormonal (disorders of ovulation, menopause, or hormonal contraceptive use), structural (polyps, myomas, or arteriovenous malformation), neoplasm (endometrial cancer), and infection (endometritis). After the history and physical examination, the initial evaluation of irregular vaginal bleeding has traditionally involved an endometrial biopsy. Transvaginal ultrasound has revolutionized the evaluation of the gynecologic ultrasound examination by providing a minimally invasive means to determine the etiology for the bleeding. Transvaginal ultrasound assessment of the endometrial cavity allows treatment to be tailored to the specific cause of irregular vaginal bleeding, thus saving women time, money, and exposure to unnecessary interventions. The purpose of this article is to give the clinician critical information regarding the capabilities of ultrasound to evaluate women with irregular vaginal bleeding.

Test characteristics of placental location screening by transabdominal ultrasound at 18-20 weeks

OBJECTIVES

To determine the test characteristics of a second-trimester transabdominal fetal anomaly scan in screening for placenta previa.

PATIENTS AND METHODS

This was a case-control study carried out at a tertiary obstetric hospital involving 54 women (0.5% of the total number booked for antenatal care and delivery at the center) with clinically significant placenta previa at the time of delivery, and 168 randomly selected controls who attended for antenatal care and delivery in 2000-2003. Sensitivity, specificity and false positive rate of the placenta-os measurement in the second-trimester transabdominal fetal anomaly scan for identification of clinically significant placenta previa were assessed.

RESULTS

Women with placenta previa at delivery had significantly different second-trimester placenta-os measurements from those of controls (P < 0.0001). For women with placenta previa, the mean (standard deviation) placenta-os measurement was -0.96 cm (1.95) vs. 4.15 cm (1.77) for controls (P < 0.0001). Using the anomaly scan as a screening test for placenta previa with a placenta-os measurement cut-off point of < or = 2 cm, all cases of placenta previa should be identified, but 11.1% (95% CI, 7.1-14.8) of women without placenta previa would have false positive results. At cut-off points of 3 cm and 1.5 cm the false positive rates were 25.7% (95% CI, 18.8-30.2%) and 6.6% (95% CI, 3.8-9.6%), respectively, but at 1.5 cm 3.8% of cases would be missed.

CONCLUSIONS

The second-trimester transabdominal fetal anomaly scan is a useful screening test for placenta previa. However, because of false positives among the much larger population of women without placenta previa, we estimate that with a cut-off point of < or =2 cm, 23 women would have to be followed up to confirm one true placenta previa.

Cervical length in women in preterm labor with intact membranes: relationship to intra-amniotic inflammation/microbial invasion, cervical inflammation and preterm delivery

OBJECTIVE

Intra-amniotic infection, diagnosed by microbial invasion of the amniotic cavity (MIAC) and/or the presence of intra-amniotic inflammation (IAI), is related to adverse perinatal outcome in women with preterm labor. Due to the subclinical nature of IAI, a correct diagnosis depends on amniocentesis, which is an invasive method not performed as a clinical routine. The aim of this study was to evaluate if cervical length measured by transvaginal sonography could assist in the identification of women at high risk for IAI.

METHODS

Cervical length was assessed by transvaginal sonography in 87 women with singleton pregnancies in preterm labor (<34 weeks of gestation). Cervical (n=87) and amniotic (n=55) fluids were collected. Polymerase chain reactions for Ureaplasma urealyticum and Mycoplasma hominis, and culture for aerobic and anaerobic bacteria, were performed. Interleukin (IL)-6 and IL-8 were analyzed by enzyme-linked immunosorbent assay.

RESULTS

IAI was present in 25/55 (45%) of the patients presenting with preterm labor who underwent amniocentesis. Women with IAI had a significantly shorter cervical length (median, 10 (range, 0-34) mm) than had those without IAI (median, 21 (range, 11-43) mm) (P<0.0001). Receiver-operating characteristics curve analysis showed that a cervical length (cut-off of 15 mm) predicted IAI (relative risk, 3.6; CI, 1.9-10.0) with a sensitivity of 72%, specificity of 83%, positive predictive value of 78% and negative predictive value of 78%. Cervical length was also significantly associated with preterm birth up to 7 days from sampling and at <or=34 weeks.

CONCLUSION

Cervical length assessed by transvaginal sonography predicts IAI as well as preterm birth and could thereby be a useful clinical tool in the management of patients in preterm labor.

Prediction of patient-specific risk of early preterm delivery using maternal history and sonographic measurement of cervical length: a population-based prospective study

OBJECTIVE

To develop a model for calculating the patient-specific risk of spontaneous early preterm delivery by combining maternal factors and the transvaginal sonographic measurement of cervical length at 22 + 0 to 24 + 6 weeks, and to compare the detection rate of this method to that achieved from screening by cervical length or maternal characteristics alone.

METHODS

This was a population-based prospective multicenter study involving 40,995 unselected women with singleton pregnancies attending for routine hospital antenatal care in London, UK. Complete follow-up was obtained from 39,284 (95.8%) cases. The main outcomes were detection rate, false-positive rate and accuracy of predicting spontaneous delivery before 32 weeks' gestation.

RESULTS

Spontaneous delivery before 32 weeks occurred in 235 (0.6%) cases. The detection rate of screening for early preterm delivery, at a fixed false-positive rate of 10%, was 38% for maternal factors, 55% for cervical length and 69% for combined testing. There was good agreement between the model estimates and the observed probabilities of preterm delivery.

CONCLUSIONS

This study provides a model that can give an accurate patient-specific risk of preterm delivery. The detection rate of screening by a combination of maternal factors and the measurement of cervical length was substantially higher than that of screening by each method alone.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.

Cervical Sonography in Women with Symptoms of Preterm Labor

In the last few years, ultrasound of the cervix during pregnancy has been the focus of much research. Significant advances have been made in its technique and in understanding the proper role of this procedure in several clinical settings. This article reviews the evidence for the clinical role of transvaginal cervical assessment in women with symptoms of preterm labor.

The cervix and prematurity: aetiology, prediction and prevention

Preventing preterm delivery remains a major challenge for the 21st century. The cervix plays a fundamental role in supporting a pregnancy and preventing ascending infection from the lower genital tract. Infection is associated with early preterm delivery in about half of cases. Whatever the aetiology of preterm delivery, dilation of the cervix is a common endpoint, and transvaginal scanning of the cervix now provides a good predictor of early preterm delivery in both high- and low-risk women. Changes in the cervix are related to the detection of fetal fibronectin in the vagina, which is also an accurate predictor of delivery. However, the role of intervention in at-risk women is unclear. Elective cerclage is only effective in a minority of women, and the evidence to support its use is limited. It is currently being evaluated whether indicated cerclage, dictated by ultrasound findings, is beneficial.

Preconceptions versus experience of transvaginal ultrasonography in older women

OBJECTIVE

To determine whether women find that having a transvaginal ultrasound scan is better or worse than they had expected.

METHODS

Fifty-four consecutive women in an ovarian cancer screening trial filled in linked questionnaires before and after having a transvaginal ultrasound scan.

RESULTS

The women found that having a transvaginal scan was less painful (P = 0.003) and less embarrassing (P = 0.001) than they had expected. They found it less uncomfortable than expected in comparison to having mammography (P = 0.013) or a cervical smear (P = 0.004).

CONCLUSIONS

Women attending for a transvaginal scan can be reassured that it will not be as painful or embarrassing as they fear, and that it is not as uncomfortable as having mammography or a cervical smear.