OBSTETRICS

OBSTETRICS

Intra-Amniotic Sludge, Short Cervix, and Risk of Preterm Delivery

Emmanuel Bujold, MD, FRCSC, Jean-Charles Pasquier, MD, Jessica Simoneau, Marie-Hlne Arpin, Louise Duperron, MD, FRCSC, Anne-Maude Morency, MD, Franois Audibert, MD
Hpital Sainte-Justine, Universit de Montral, Montral (Qubec)

Abstract
Objective: To evaluate the association between intra-amniotic sludge seen at cervical ultrasound and preterm delivery. Method: This retrospective study included women at high risk for preterm delivery who were referred for second trimester cervical length measurement by ultrasound between 18 and 32 weeks gestation. Patients with multiple gestations, cerclage, or preterm labour were excluded. Ultrasound images were reviewed by two independent observers and divided into three groups: (1) no amniotic sludge, (2) light sludge, and (3) dense sludge in the amniotic fluid. The primary outcome measures were delivery within 14 days of examination and delivery before 34 weeks gestation. Logistic regression analyses were performed to adjust for confounding factors. Results: Eighty-nine patients met the inclusion criteria. Mean gestational age at presentation was 25.8 4.4 weeks, and mean cervical length was 33 12 mm. The prevalence of light and dense amniotic fluid sludge was 10.1% and 5.6%, respectively. Delivery within 14 days of examination occurred in four (5.3%) women with no sludge, in two (22.2%) women with light sludge, and in three (60.0%) women with dense sludge (P < 0.01). Delivery before 34 weeks occurred in five (6.7%), four (44.4%) and four (80.0%) women, respectively (P < 0.01). Logistic regression analyses demonstrated that light amniotic fluid sludge, dense sludge, and cervical length of less than 25 mm were all significant and independent predictors of delivery within 14 days of examination and delivery prior to 34 weeks. Conclusion: The presence of amniotic fluid sludge is associated with delivery within 14 days and delivery before 34 weeks gestation.

(3) agrgats denses dans le liquide amniotique. Les critres dvaluation primaires taient laccouchement dans les 14 jours e suivant lexamen et laccouchement avant la 34 semaine de gestation. Des analyses de rgression logistique ont t effectues pour neutraliser leffet des facteurs confusionnels. Rsultats : Quatre-vingt-neuf patientes ont satisfait aux critres dinclusion. Lge gestationnel moyen au moment de la prsentation tait de 25,8 4,4 semaines et la longueur cervicale moyenne tait de 33 12 mm. La prvalence des agrgats lgers et denses dans le liquide amniotique tait de 10,1 % et de 5,6 %, respectivement. Un accouchement dans les 14 jours suivant lexamen a t constat chez quatre (5,3 %) des femmes ne prsentant pas dagrgats, chez deux (22,2 %) des femmes prsentant de lgers agrgats et chez trois (60,0 %) des femmes prsentant des agrgats denses (P < 0,01). Un accouchement e avant la 34 semaine de gestation a t constat chez cinq (6,7 %), quatre (44,4 %) et quatre (80,0 %) de ces femmes, respectivement (P < 0,01). Les analyses de rgression logistique ont dmontr que la prsence dagrgats lgers ou denses dans le liquide amniotique et quune longueur cervicale infrieure 25 mm constituaient toutes deux des prdicteurs significatifs et indpendants de laccouchement dans les 14 jours suivant e lexamen et de laccouchement avant la 34 semaine de gestation. Conclusion : La prsence dagrgats dans le liquide amniotique est associe laccouchement dans les 14 jours suivant lexamen et e laccouchement avant la 34 semaine de gestation. J Obstet Gynaecol Can 2006;28(3):198202

INTRODUCTION

Rsum
Objectif : valuer lassociation entre les agrgats intra-amniotiques constats par chographie cervicale et laccouchement prmatur. Mthode : La prsente tude rtrospective sest penche sur des femmes, courant des risques levs de connatre un accouchement prmatur, qui ont t orientes vers des services de mesure de la longueur cervicale au deuxime trimestre par e e chographie, entre la 18 et la 32 semaine de gestation. Les patientes prsentant des gestations multiples, un cerclage ou un travail prterme ont t exclues. Les images chographiques ont t analyses par deux observateurs indpendants et divises en trois groupes : (1) aucun agrgat amniotique, (2) agrgats lgers et Key Words: Pregnancy, cervical length, amniotic fluid, ultrasound, preterm birth Competing Interests: None declared. Received on December 12, 2005 Accepted on January 10, 2006

espite improvements in prenatal care, preterm birth continues to be a leading cause of perinatal death, and the rate of spontaneous preterm births has not decreased in the past 30 years.1,2 Two main factors contribute to such disappointing figures: the inadequacy of our therapeutic arsenal and the absence of reliable criteria for identifying a population at high risk for preterm delivery.

Measurement of cervical length is one of the most recent tools that help in the prediction of preterm birth. Short cervical length, usually defined as below the tenth percentile, or < 25 mm measured by transvaginal ultrasound examination, has been strongly related to the risk of preterm birth.3,4 Despite an excellent negative predictive value, the positive predictive value of this measurement in asymptomatic women remains low.4 Moreover, the cause of a short cervix

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Intra-Amniotic Sludge, Short Cervix, and Risk of Preterm Delivery

has not been elucidated and is probably multifactorial. Possible contributing factors include uterine contractions, inflammation, and other unknown mechanisms, making effective therapy even more difficult to develop.5 Recently, Espinoza and colleagues demonstrated that the presence of intra-amniotic fluid sludge, a cluster of particulate matter sitting close to the cervical os, was associated with microbial invasion of the amniotic cavity, histological chorioamnionitis, and impending preterm delivery in patients with preterm labour and intact membranes.6 Seventy-one percent of women found to have intra-amniotic sludge were delivered in the seven days following identification, compared with 16% of women without intra-amniotic sludge. These very important findings suggest that this is an index with high positive predictive value for preterm birth. The objectives of this study were (1) to evaluate the presence of intra-amniotic sludge in a subgroup of women at high risk for preterm delivery but without the diagnosis of preterm labour, and (2) to correlate the finding of intra-amniotic sludge with the risk of subsequent preterm delivery.
MATERIALS AND METHODS

When there was no agreement between the two sonographers, a third independent sonographer blinded to the obstetrical outcomes was consulted for the appropriate classification. All transvaginal ultrasounds were performed with commercially available ultrasound systems (ATL HDI-3500 and ALOKA SSD-5500). Gestational age at the time of ultrasonographic examination and at delivery was confirmed by an ultrasound performed prior to 20 weeks gestation in all women included in the study. The medical records of each patient included in the study were reviewed by an independent observer blinded to the ultrasound findings. The following information was collected: maternal age, gravidity, parity, previous preterm delivery, the reason for measuring cervical length, date of delivery, gestational age at delivery, birth weight, and presence or absence of histological chorioamnionitis recorded in the pathology report (systematically recorded for all deliveries in our centre). Patients with no sludge, light sludge, or dense sludge were compared. The primary outcomes were delivery within 14 days of ultrasound examination and delivery before 34 weeks gestation. The other adverse outcomes measured were the interval between ultrasound examination and delivery, delivery before 37 weeks gestation, and histological chorioamnionitis. Multiple stepwise logistic regression analyses were performed to adjust for confounding factors, including intra-amniotic sludge, short cervical length (< 25 mm), nulliparity, prior preterm delivery, and advanced maternal age. The amniotic sludge variable was measured as a categorical variable divided into three groups. These factors were selected prior to study performance. Subsequent regression analyses with 15 mm as a cut-off for cervical length instead of 25 mm were also undertaken. The chi-square test, Fisher exact test, Student t test, and the Kruskal-Wallis test were used when appropriate. SPSS 13.0 (SPSS Inc., Chicago, IL) was used for the statistical analyses, and P values < 0.05 were considered to be statistically significant.
RESULTS

After approval of our research protocol by the Scientific and Ethics Committees of Hpital Sainte-Justine, a retrospective study was conducted by searching our digital library of ultrasound images collected at the Antenatal Ultrasound Centre of our institution between January 2004 and April 2005. The inclusion criteria were (1) women with a live singleton pregnancy referred for a transvaginal ultrasonographic measurement of cervical length and (2) gestational age between 18 and 32 weeks gestation. The exclusion criteria were (1) women with a diagnosis of preterm labour or with regular uterine contractions on the day of examination, (2) multiple gestation, (3) fetal anomalies or fetal intrauterine growth restriction, (4) cervical cerclage, and (5) placenta previa. The ultrasound images were reviewed by two independent sonographers blinded to the obstetrical outcomes to record the measured cervical length and the presence or absence of intra-amniotic fluid sludge. Amniotic fluid sludge was defined as dense aggregates of particulate matter seen on ultrasound in proximity to the internal cervical os, as described previously by Espinoza et al.6 In some cases, the particulate matter was less dense and clustered, and the sonographers classified these cases as light sludge. Therefore, the patients were classified into three groups: (1) no amniotic sludge; (2) light sludge, when the particulate matter was not clustered; and (3) dense sludge, when the particulate matter was clustered in the amniotic fluid (see Figure).

During the study period, 89 patients met the inclusion criteria. Although the specific reason for the cervical ultrasound examination was not available in several cases, we found that nine women had a diagnosis of preterm labour, 39 women had a diagnosis of threatened preterm labour (with no change in cervical dilatation on examination) that was resolved, and 24 (27%) had a history of preterm delivery. Mean gestational age at presentation was 25.8 4.4 (mean standard deviation) weeks, and mean cervical length was 33 12 mm. Light sludge was noted in 10.1% (9/89) and dense sludge in 5.6% (5/89) of examinations; 76
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Intra-amniotic sludge during second trimester transvaginal ultrasound examination A) two women with no intra-amniotic sludge, B) two women with light intra-amniotic sludge, C) two women with dense intra-amniotic sludge (the sludge was delimited on the second image).

FH: fetal head; LS: light sludge; DS: dense sludge.

(85.4%) women did not show any sign of intra-amniotic sludge on their ultrasound images. The two independent sonographers agreed on the classification of 87 (98%) of 89 cases, and they were in complete agreement with the classification of the five cases with dense sludge. The clinical characteristics of the women included in the study according to the presence of amniotic sludge are reported in Table 1. We found that women with intra-amniotic sludge had shorter cervical length than those without. Table 2 compares the obstetrical outcomes according to the presence of amniotic sludge. Women with intra-amniotic sludge, and particularly those with dense intra-amniotic sludge, were more likely to deliver within 14 days of the examination, before 34 weeks gestation, before 37 weeks gestation, and to have a diagnosis of histological chorioamnionitis. Logistic regression analyses demonstrated that the presence of dense intra-amniotic fluid sludge and cervical length < 25 mm were both significant independent predictors of delivery within 14 days and independent predictors of delivery < 34 weeks (Table 3). We subsequently decided to repeat the multivariable logistic regression analysis with cervical length < 15 mm as the confounding factor. The presence of dense intra-amniotic sludge remained a significant predictor of delivery < 34 weeks (odds ratio [OR] 23.3; 95% confidence interval [CI] 1.2, 470.1). Finally, Table 4 shows the rate of subsequent adverse outcomes according to the presence or absence of both short cervix and intra-amniotic sludge at the time of transvaginal examination. The combination of both factors was associated with a very high rate of delivery before 34 weeks gestation (75%) and delivery within 14 days of examination (50%).
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DISCUSSION

Our study reveals that intra-amniotic sludge during transvaginal examination is linked with a very high likelihood of delivery before 34 weeks gestation and also with a high risk of delivery within the next 14 days. Moreover, even if the presence of intra-amniotic sludge was associated with shorter cervical length, it remained an independent risk factor related to these adverse outcomes after adjustment for short cervical length. Finally, intra-amniotic sludge was a risk factor for delivery before 37 weeks gestation and histological chorioamnionitis. These findings are in agreement with the data of Espinoza and colleagues, who studied the clinical significance of amniotic fluid sludge in 84 patients with preterm labour and intact membranes.6 Intra-amniotic sludge in this subgroup of women was associated with spontaneous delivery within 48 hours (OR 19.6; 95% CI 1.5, 257.4) and within seven days (OR 11.7; 95% CI 1.7, 81.6), positive amniotic fluid culture (OR 19.2; 95% CI 1.14, 332), and histological chorioamnionitis (OR 8.3; 95% CI 1.3, 50.9). Because intra-amniotic sludge was accompanied by microbial invasion of the amniotic cavity, they suggested that the particulate matter that constituted intra-amniotic sludge could potentially be bacterial biofilms, a matrix of polymeric compounds that microorganisms may produce to protect themselves from host defence mechanisms.6,7 Since intra-amniotic microbial invasion at the time of second trimester amniocentesis has been reported to be more frequent in women who will subsequently deliver prematurely,8-11 we believe that the hypothesis of Espinoza and colleagues remains valid in light of our findings. Amniocenteses, to rule out microbial

Intra-Amniotic Sludge, Short Cervix, and Risk of Preterm Delivery

Table 1. Clinical characteristics of the study population according to the presence of intra-amniotic sludge
No sludge n = 75 Maternal age (years SD) Gravida, median (min, max) Parity, median (min, max) Previous preterm birth Gestational age at examination (weeks SD) Cervical length at examination (mm SD)
SD: standard deviation.

Light sludge n=9 31.9 5.3 4 (1, 11) 1 (0, 5) 3 (33.3%) 24.2 4.5 23 11

Dense sludge n=5 31.2 3.0 3 (2, 4) 1 (0, 3) 1 (20%) 22.7 3.5 16 14

P 0.91 0.12 0.34 0.86 0.12 0.01

32.1 4.3 2 (1, 6) 1 (0, 3) 20 (26.7%) 25.8 3.6 34 10

Table 2. Obstetrical outcomes according to the presence of amniotic fluid sludge

No sludge n = 75 Gestational age at birth (weeks SD) Gestational age at birth < 34 weeks < 37 weeks Interval between examination and birth (days SD) Interval between examination and birth = 14 days Birth weight (grams SD) Histological chorioamnionitis
SD: standard deviation

Light sludge n=9 35.4 4.4 4 (44.4%) 4 (44.4%) 76 55 2 (22.2%) 2,426 850 1 (11.1%)

Dense sludge n=5 27.9 7.3 4 (80.0%) 4 (80.0%) 36 65 3 (60.0%) 1304 1,282 3 (60.0%)

P < 0.01 < 0.01 < 0.01 0.02 < 0.01 < 0.01 < 0.01

38.2 2.8 5 (6.7%) 13 (17.3%) 87 34 4 (5.3%) 3178 694 4 (5.3%)

invasion of the amniotic cavity, were not performed in our study. The observed rate of intra-amniotic light or dense sludge between 18 and 32 weeks gestation in our high-risk population (15.7%) is also in agreement with the work of Zimmer and Bronshtein, who reported their intra-amniotic findings from 6500 transvaginal ultrasound examinations performed between 14 and 16 weeks gestation in both low- and high-risk women.12 Two hundred six (3.3%) of these women demonstrated solid or semi-solid intra-amniotic material in fetuses without malformation. However, obstetrical outcomes were not reported in this study population. We did not find any other investigation that examined obstetrical outcomes related to intra-amniotic sludge. The limitations of our study include its retrospective nature, the small number of patients with intra-amniotic sludge and the unavailability of the specific reason for the cervical ultrasound examination. Another potential source of bias is that the sonographic examinations were obtained for clinical use, and managing physicians were not blinded. However, we believe that potential biases were avoided because of the following: (1) the sonographers and the research

assistant who performed the chart reviews were all blinded to the findings of the others; (2) definitions of intra-amniotic sludge, primary outcomes, and potential confounders were planned prior to data collection; (3) the two independent investigators were in agreement with the classification on 98% of the cases; and (4) the association between intra-amniotic sludge and preterm birth had not been published prior to performing the current study. The specific reason for cervical length measurement was unavailable for approximately one-quarter of the patients, and it is therefore difficult to apply our results directly to a specific population in clinical practice. However, because cervical ultrasound examination is not routinely performed in our centre and is usually reserved for patients at higher risk of preterm delivery, we believe that our study population represents a reasonably homogeneous subgroup of women at high risk for preterm delivery. Finally, the new definition of light sludge has both limitations and benefits: this intermediate state between the absence of sludge and dense sludge is not easy to describe, but there was agreement by both sonographers about its presence, and it was also associated with an intermediate risk of adverse obstetrical outcomes.
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Table 3. Multivariable stepwise logistic regression for predictive factors of delivery before 34 weeks gestation and for delivery 14 days after examination
Factors Odds ratio (95% CI) Delivery before 34 weeks gestation Cervical length < 25 mm Amniotic fluid sludge* Light Dense 6.82 (1.17, 39.79) 45.99 (3.48, 608.50) Delivery 14 days after examination Cervical length < 25mm Amniotic fluid sludge* Light Dense
* Compared with no sludge

7.90 (1.69, 37.05)

< 0.01 0.03 < 0.01 < 0.05 0.30 0.01

5.24 (1.02, 27.91)

2.86 (0.39, 21.10) 17.77 (1.97, 160.26)

Table 4. Frequency of delivery before 34 weeks gestation and within 14 days of examination according to the presence or absence of short cervix and intra-amniotic sludge
Cervical length < 25 mm No Yes No Yes Prevalence of the outcome
* Light or dense sludge present at the time of cervical length measurement.

Presence of intra-amniotic sludge* No No Yes Yes

Delivery before 34 weeks gestation 2/61 (3.3%) 3/14 (21.4%) 2/6 (33.3%) 6/8 (75.0%) 13/89 (14.6%)

Delivery within 14 days of examination 2/61 (3.3%) 2/14 (14.3%) 1/6 (16.7%) 4/8 (50.0%) 9/89 (10.1%)

CONCLUSION

4. Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, et al. The length of the cervix and the risk of spontaneous premature delivery. N Engl J Med 1996;334:56772. 5. Gomez R, Romero R, Nien JK, Chaiworapongsa T, Medina L, Kim YM, et al. A short cervix in women with preterm labor and intact membranes: a risk factor for microbial invasion of the amniotic cavity. Am J Obstet Gynecol 2005;192(3):67889. 6. Espinoza J, Goncalves LF, Romero R, Nien JK, Stites S, Kim YM, et al. The prevalence and clinical significance of amniotic fluid sludge in patients with preterm labor and intact membranes. Ultrasound Obstet Gynecol 2005;25:34652. 7. Leid JG, Shirtliff ME, Costerton JW, Stoodley AP. Human leukocytes adhere to, penetrate, and respond to Staphylococcus aureus biofilms. Infect Immun 2002;70:633945. 8. Gray DJ, Robinson HB, Malone J, Thomson RB Jr. Adverse outcome in pregnancy following amniotic fluid isolation of Ureaplasma urealyticum. Prenat Diagn 1992;12:1117. 9. Cassell GH, Davis RO, Waites KB, Brown MB, Marriott PA, Stagno S, et al. Isolation of Mycoplasma hominis and Ureaplasma urealyticum from amniotic fluid at 1620 weeks of gestation: potential effect on outcome of pregnancy. Sex Transm Dis 1983;10:294302. 10. Horowitz S, Mazor M, Romero R, Horowitz J, Glezerman M. Infection of the amniotic cavity with Ureaplasma urealyticum in the midtrimester of pregnancy. J Reprod Med 1995;40:3759. 11. Gerber S, Vial Y, Hohlfeld P, Witkin SS. Detection of Ureaplasma urealyticum in second-trimester amniotic fluid by polymerase chain reaction correlates with subsequent preterm labor and delivery. J Infect Dis 2003;187:51821. 12. Zimmer EZ, Bronshtein M. Ultrasonic features of intra-amniotic unidentified debris at 1416 weeks gestation. Ultrasound Obstet Gynecol 1996;7:17881.

Our observations, combined with those of Espinoza and colleagues,6 indicate that the sonographic finding of intra-amniotic sludge is an important and independent risk factor for delivery before 34 weeks gestation and for impending delivery in women with or without the clinical diagnosis of preterm labour. The likelihood of microbiological invasion of the amniotic cavity or subsequent histological chorioamnionitis warrants further, larger studies to confirm our results and to evaluate the benefits of amniocentesis and specific therapeutics, such as antibiotics, in the subgroup of patients with intra-amniotic sludge.
REFERENCES
1. Ventura SJ, Martin JA, Curtin SC, Menacker F, Hamilton BE. Births: final data for 1999. Natl Vital Stat Rep 2001;49:1100. 2. McCormack MC. The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 1985;312:8290. 3. Rozenberg P, Gillet A, Ville Y. Transvaginal sonographic examination of the cervix in asymptomatic pregnant women: review of the literature. Ultrasound Obstet Gynecol 2002;19:30211.

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