CAOG Papers

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Transvaginal cervical length and amniotic fluid

index: can it predict delivery latency following
preterm premature rupture of membranes?
Suwan Mehra, MD; Erol Amon, MD; Sarah Hopkins, PhD; Jeffrey A. Gavard, PhD;
Jaye Shyken, MD
OBJECTIVE: We sought to determine whether transvaginal cervical

length (TVCL), amniotic fluid index (AFI), or a combination of both can

predict delivery latency within 7 days in women presenting with preterm premature rupture of membranes (PPROM).
STUDY DESIGN: This was a prospective observational study of

TVCL measurements in 106 singleton pregnancies with PPROM

between 23-33 weeks. Delivery latency was defined as the period
(in days) from the initial TVCL after PPROM to delivery of the infant,
with our primary outcome being delivery within 7 days of TVCL. The
independent predictability of significant characteristics for delivery
within 7 days was determined using multiple logistic regression.
Sensitivity, specificity, and predictive values were used to examine
whether the presence of a short TVCL, AFI, or a combination of both
affected the risk of delivery within 7 days.
RESULTS: Delivery within 7 days occurred in 51/106 (48%) of pregnancies. Median duration (interquartile range) from PPROM to
delivery and TVCL to delivery was 8 days (4.0e16.0) and 8 days
(3.0e15.0), respectively. Using multiple regression TVCL as a
continuous variable (odds ratio, 0.65; 95% confidence interval,
0.44e0.97; P < .05), AFI
5 cm (odds ratio, 4.69; 95% confidence

interval, 1.58e13.93; P < .01) were determined to be independent

predictors of delivery within 7 days. In all, 42 women (40%) had a TVCL

2 cm, while 62 (59%) had AFI
5 cm. A total of 26 women (25%)
had a combination of both TVCL
2 cm and AFI
5 cm, while 28
women (27%) had neither characteristic. The predictive value of delivery within 7 days for a TVCL
2 cm was 62%, and for an AFI
5 cm
was 58%. Having a combination of low TVCL and low AFI did not increase the predictive value of delivery within 7 days (58%). In contrast,
only 3 of 27 women (11%) with neither characteristic delivered within
7 days. The predictive value of delivery >7 days for TVCL >2 cm alone
was 61%. This predictive value changed when analyzed in conjunction
with an AFI
5 cm and >5 cm at 42% and 89%, respectively.
CONCLUSION: A shorter TVCL and an AFI
5 cm independently

predict delivery within 7 days in women presenting with PPROM.

The combination of an AFI >5 cm and TVCL >2 cm greatly improved
the potential to remain undelivered at 7 days following cervical
length assessment. These findings may be helpful for counseling
and optimizing maternal and neonatal care in women with PPROM.
Key words: amniotic fluid index, cervical length, labor latency,
preterm birth, preterm premature rupture of membranes

Cite this article as: Mehra S, Amon E, Hopkins S, et al. Transvaginal cervical length and amniotic fluid index: can it predict delivery latency following preterm premature
rupture of membranes? Am J Obstet Gynecol 2015;212:400.e1-9.

reterm premature rupture of

membranes (PPROM) is a breach
of the chorioamniotic membrane prior
to the onset of labor at <37 weeks of
gestation. It affects up to 3% of all
pregnancies.1,2 and accounts for about
one third of all preterm births.3 The rate

From the Department of Obstetrics,

Gynecology, and Womens Health, Saint Louis
University School of Medicine, St. Louis, MO.
Received Aug. 25, 2014; revised Dec. 15, 2014;
accepted Jan. 12, 2015.
The authors report no conict of interest.
Corresponding author: Suwan Mehra, MD.
smehra@slu.edu
0002-9378/$36.00
2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.01.022

of preterm birth, 12.8% in 2006, represents a 36% increase since 1981.4

Patients with PPROM are often hospitalized for a prolonged period of time,
and deliver premature infants who
frequently require neonatal intensive
care.3,5 These women and their infants
contribute signicantly to obstetric and
neonatal health care costs.6 Predicting
the time to delivery (latency) is difcult
for an individual patient, leading to uncertainty for both the patient and the
health care provider. The prediction of
delivery latency could help direct the
need for specic interventions such as
hospitalization, intensive monitoring,
timing of antenatal steroids, and magnesium for neuroprotection.3,7
Transvaginal ultrasound (TVU) for
the determination of cervical length

400.e1 American Journal of Obstetrics & Gynecology MARCH 2015

(CL) has been demonstrated to

predict the risk of preterm delivery with
intact membranes in both singletons and
twin gestations.8-11 The safety of serial
TVU is consistently reported with no
signicant increase in endometritis,
chorioamnionitis, or neonatal infection
in women with PPROM.12,13 Still,
the use of TVU has previously been
avoided in the presence of ruptured
membranes; therefore, its use in the
management of PPROM has been
infrequently studied. Studies show that
accurate measurement of CL cannot
be reproduced as reliably with either
abdominal or translabial ultrasound.14
CL by translabial ultrasound was
not found to be associated with the
duration of latency period following
PPROM.15

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A few studies reported that a CL <2
cm may be associated with a shorter
latency to delivery.13,16,17 Prior studies
found that a low (
5 cm) amniotic
uid index (AFI) in PPROM is associated with a shorter latency and a higher
rate of delivery within 7 days compared
to women with a normal AFI.18-21
However, it is unclear how these 2 clinical variables can be used, either

independently or in combination with

CL, to help predict delivery latency.
The purpose of this study was to
examine the relationship among CL,
amniotic uid volume, and latency in
women presenting with PPROM. Secondly, we sought to determine how
other variables predict latency in this
population. We hypothesized that
after PPROM, an initial transvaginal

FIGURE 1

Study inclusion characteristics

PPROM, preterm premature rupture of membranes.

Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

CL (TVCL) would independently predict the latency period within 7 days

and that AFI would improve this predictive ability.

M ATERIALS

AND

M ETHODS

The study was conducted from July

2011 through March 2014 at a single
perinatal center. This study was
approved by the Institutional Review
Board at Saint Louis University. This was
a prospective observational study in
women with PPROM who consented
to undergo TVCL measurement after
admission.
Eligible women included nonlaboring
patients, ages 16, with singleton
gestation who presented with PPROM
between the gestational age (GA) of 23
weeks 5 dayse33 weeks 6 days. PPROM
was diagnosed by history and physical
examination, which included documentation of nitrazine- or fern-positive
pooled vaginal uid obtained by sterile
speculum examination. In equivocal
cases a placental alpha microgobulin-1
protein assay was performed from the
vaginal uid sample. GA was calculated
from the rst day of the last normal
menstrual period and an ultrasound
in early pregnancy when available.
Women were excluded prior to enrollment for labor (dened as painful
uterine contractions 12 in an hour
and cervical dilation of >3 cm
conrmed by digital examination), for
being non-English speaking, or for
having had >1 digital examination
following PPROM. Following study
enrollment women were excluded for
a variety of reasons (Figure 1).
All women were hospitalized and
placed on modied bed rest. TVCL was
performed within 72 hours of admission
using the CLEAR guidelines.22 Measurements of the TVCL were taken after
visualizing the endocervical canal in its
entirety for 3-5 minutes, with an empty
maternal bladder. Calipers were placed
where the anterior and posterior walls
of the cervix were sonographically
opposed and the shortest technically
best measurements were used. The
presence of funneling was noted. AFI
was recorded at the time of the TVCL
measurement. Prophylactic antibiotics

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400.e2

CAOG Papers
used included ampicillin 2 g intravenously every 6 hours and azithromycin
500 mg intravenously daily for 2 days,
followed by oral amoxicillin 250 mg
every 8 hours and azithromycin 500 mg
daily for 5 days. Two doses of 12 mg
betamethasone were given intramuscularly, 24 hours apart. Tocolysis was
generally administered during transport.
Additional digital examinations were
prohibited without visual evidence of
cervical change. Expectant management
was followed until 34 weeks gestation.
Our primary endpoint was a latency
period within 7 days from performance
of the TVCL at admission. To provide a
more meaningful risk assessment for
clinical purposes, TVCL and AFI were
analyzed as dichotomous variables as

2.0 and >2.0 cm for TVCL, and
5
and >5 cm for AFI. Sensitivity, specicity, and predictive values were used
to examine whether the presence of
TVCL, AFI, or a combination of both
characteristics affected the risk of delivery within 7 days.
Comparative analyses were undertaken to determine whether other variables affected latency. Demographic,
medical, obstetrical, sonographic, and
delivery variables were recorded such
as GA at PPROM, history of PPROM
or preterm delivery, tobacco and drug
use, history of cervical procedures,
visual cervical dilation at admission,
presence of vaginal bleeding, digital
examination performed prior to admission, and presence or absence of
funneling at the TVCL assessment.
We based our preliminary sample
size estimates on previously published
PPROM data from Tsoi et al.17 In that
study of women with a CL
2.0 cm, 76%
delivered within 7 days compared to
only 29% of women with a TVCL >2.0
cm. To detect a similar magnitude of difference with a power of 0.8, alpha <0.05, a
sample size of at least 18 women per
TVCL comparison groups were required.
Differences in demographic characteristics,
medical/obstetrical
history,
and clinical/delivery characteristics were
compared between women who delivered

7 days vs >7 days using c2, Fisher
exact test, and independent Students t test
for continuous variables that were

ajog.org

TABLE 1

Demographic/medical/obstetric data by delivery latency at 1 week

Demographic

7 d
(n [ 51)

>7 d
(n [ 55)

Maternal age, y

25.0

(22.0e32.0)

25.0

(20.0e30.0)

Nulliparous

25

49.0

24

43.6

Caucasian

26

51.0

33

60.0

African American

23

45.1

21

38.2

3.9

1.8

P value
1.00
.58

Race

Other

.58

Body mass index, kg/m2

29.3

(24.5e33.8)

27.8

(23.3e35.2)

.21

Smoking

21

41.2

19

34.5

.48

Illicit drug use

10

19.6

5.5

< .05

Private

11

21.6

13

24.1

.10

Medicaid

33

64.7

25

46.3

Self-pay

13.7

16

29.6

10

19.6

9.1

.12

Pregnancy with PPROM

12

23.5

3.6

< .01

Preterm birth

17

33.3

10.9

< .01

Cervical incompetence

5.9

3.6

.67

LEEP or cone biopsy

9.8

7.3

.74

Insurance

Medical history
Asthma
Obstetrical history

Data are expressed as median (interquartile range) for continuous variables, and as number and percentage for categorical
variables. Insurance was unknown for 1 woman.
LEEP, loop electrosurgical excision procedure; PPROM, preterm premature rupture of membranes.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

normally distributed. The nonparametric

Kolmogorov-Smirnov test was used for
continuous variables that were not normally distributed. Cox regression was used
to compare the relationships of latency
from PPROM to delivery and from CL to
delivery. The independent predictability of
statistically signicant univariate characteristics on latency from initial TVCL was
examined by multiple logistic regression.
Sensitivity, specicity, and predictive value
were calculated for TVCL (
2.0 cm and
>2.0 cm) and AFI (
5.0 cm and >5.0
cm) in relation to the latency period of 7
days. Positive predictive value (PPV) was
dened as the probability for delivery
within 7 days from the TVCL. Negative
predictive value (NPV) was dened as the
probability of remaining pregnant >7

400.e3 American Journal of Obstetrics & Gynecology MARCH 2015

days. A P value < .05 was used to denote

statistical signicance. All analyses
were performed using software (SPSS,
Version 21.0; IBM Corp, Armonk, NY).

R ESULTS
In all, 129 singleton women with suspected PPROM consented for the study.
Figure 1 illustrates the reasons for postconsent exclusions: 106 were included
for nal analysis.
Subjects were between 18-41 years of
age, with approximately 90% of cases
occurring <35 years. The body mass
index
(BMI)
ranged
between
19.6e64.8 kg/m2. All transported women
had corticosteroids, tocolysis, and latency
antibiotics initiated for transfer. Approximately one third of women had a single

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vaginal examination performed at the
referring hospital prior to the TVCL
assessment. A third of women had a
closed cervix visualized on sterile speculum examination on admission. In all, 68
women (64%) had a TVCL performed
within 1 day of PPROM, 92 (87%) within
2 days, and 103 (97%) within 3 days. The
mean TVCLwas 2.5  1.3 cm (1 SD); 29%
had a TVCL
1.5 cm and 19%,
1.0 cm.
Of cases, 10% had anhydramnios at
admission. Using a Cox regression we
assessed latency interval from performance of the TVCL in relation to latency
interval from PPROM. Accordingly there
was no signicant difference in delivery
rates within 7 days of PPROM and 7 days

of initial TVCL: 49/106 (46.2%) and 51/

106 (48.1%), respectively.
The univariate relationships of demographic, medical, obstetrical, sonographic, and delivery variables for
7
days and >7 days of latency from the
TVCL measurement are summarized in
Tables 1-3. CL and AFI were each
signicantly associated with delivery
within 7 days. The median TVCL was
signicantly shorter and an AFI (
5 cm)
was signicantly more frequent in
women who delivered
7 days. A latent
period
7 days was also signicantly
associated with a later GA at TVCL,
prior preterm birth, prior PPROM,
illicit drug use, and uterine contractions.

Using signicant variables from univariate analyses a stepwise multiple logistic regression model was performed
(Table 4).
We examined screening parameters
for TVCL and AFI as dichotomous variables for the prediction of the latent
period of 1 week from TVCL (Table 5).
In all, 42 women (40%) had a TVCL
2
cm while 62 (59%) had an AFI
5 cm.
Of 105 women, 26 (25%) had a combination of both TVCL
2 cm and AFI

5 cm, while 27 of 105 women (26%)
had neither characteristic. Having a
combination of low TVCL and low AFI
did not increase the PPV of delivery
within 7 days (58% for low TVCL/low

TABLE 2

Clinical and sonographic characteristics by delivery latency at 1 week

Characteristic

7 d
(n [ 51)

>7 d
(n [ 55)

P value

Maternal transports

36

70.6

43

79.6

Gestational age at PPROM, wk

31.4

(29.4e33.0)

28.7

(26.9e31.0)

< .001

Gestational age at first cervical length, wk

31.6

(29.4e33.1)

28.9

(27.0e31.3)

< .001

1.0

(1.0e2.0)

1.0

(1.0e2.0)

1.00

Duration from PPROM to first cervical length, d

.28

Digital cervical examinations following PPROM

0

31

60.8

38

69.1

20

39.2

17

30.9

Cervical dilation at admission, cm

1.0

.37

(0.0e2.0)

1.0

(0e1.0)

.21

Vaginal bleeding prior to PPROM

10

19.6

12.7

.34

Uterine contractions any time before PPROM

18

35.3

10

18.2

< .05

Uterine contractions immediately before PPROM

14

27.5

9.1

< .05

Uterine contractions after PPROM

27

52.9

14

25.9

< .01

Positive group-B streptococcus culture

12

24.0

15

27.3

.70

Positive gonococcus or chlamydia DNA

3.9

5.6

1.00

Cervical length, cm

2.1

(0.9e3.1)

3.0

(1.9e3.7)

< .01

Amniotic fluid index, cm

3.5

(1.3e5.3)

5.2

(2.7e8.4)

< .05

Funneling

16.0

13

23.6

.33

Cephalic

37

72.5

37

67.3

.41

Breech

13

25.5

14

25.5

Transverse

0.0

03

5.5

Funic

2.0

1.8

Fetal presentation at first ultrasound

Data are expressed as median (interquartile range) for continuous variables, and as number and percentage for categorical variables. Cervical dilation at admission was unknown for 2 women.
Uterine contractions after PPROM, group-B streptococcus, and funneling were unknown for 1 woman.
PPROM, preterm premature rupture of membranes.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

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TABLE 3

Delivery characteristics by delivery latency at 1 week

7 d
(n [ 51)

Characteristic
Gestational age at delivery, wk

>7 d
(n [ 55)

31.9

Birthweight, g

1685

(29.4e33.9)
(1415e2116)

31.5
1723

P value
(29.3e33.5)
(1348e2183)

.69
.28

Duration from PPROM to delivery, d

4.0

(3.0e6.0)

16.0

(11.0e22.3)

< .001

Duration from first cervical length to delivery, d

3.0

(2.0e4.0)

15.0

(10.0e20.0)

< .001

Cord prolapse after PPROM

3.9

3.7

39

76.5

41

75.9

Indicated delivery

17.6

11.1

Induced for 34 wk

5.9

13.0

Vaginal

33

64.7

32

59.3

Cesarean

18

35.3

22

40.7

15.7

12

22.7

.39

Histological chorioamnionitis

31

70.5

37

80.4

.27

Funisitis

17

38.6

25

54.3

.14

2.0

5.0

.62

1.00

Delivery
Spontaneous delivery

.34

Mode of delivery

Clinical chorioamnionitis

Endometritis

.57

Data are expressed as median (interquartile range) for continuous variables, and as number and percentage for categorical variables. Delivery outcomes were unknown for 1 woman. Placental
findings were unknown for 16 women.
PPROM, preterm premature rupture of membranes.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

AFI compared to either characteristic

alone, 62% for low TVCL, and 58%
for low AFI) (Table 5). Only 3 of 27
women (11%) who had neither

characteristic delivered within 7 days.

The NPV overall for TVCL >2 cm was
61%. The NPV changed when TVCL >2
cm was analyzed together with an AFI

TABLE 4

Final multiple logistic regression models predicting delivery latency for

104 women with PPROM
7 d from initial cervical length
Characteristic

OR

95% CI

P value

Prior pregnancy with PPROM

10.62

1.84e61.45

< .01

Gestational age at cervical length, wk

1.35

1.12e1.63

< .01

Uterine contractions after PPROM

5.55

1.91e16.11

< .01

Cervical length, cm

0.65

0.44e0.97

< .05

Amniotic fluid index (
5 cm)

4.69

1.58e13.93

< .01

Final multiple logistic regression model predicting delivery latency for each time period was generated from characteristics that
were statistically significant in univariate group comparisons. Amniotic fluid index was entered as dichotomous categorical
variable (
5 cm and >5 cm). Final model was based on 104 women, since uterine contractions after PPROM and amniotic
fluid index were unknown for 1 woman each. Only gestational age at cervical length (and not at PPROM) was included in model.
CI, confidence interval; OR, odds ratio; PPROM, preterm premature rupture of membranes.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

400.e5 American Journal of Obstetrics & Gynecology MARCH 2015

5 cm (42%) and AFI >5 cm (89%)

(Table 5).
Tables 6 and 7 describe the analysis of
these testing parameters stratied by a
GA in women
30 and >30 weeks,
respectively. Compared to the overall
cohort the NPV of these tests were
enhanced in women
30 weeks at
PPROM. In women >30 weeks at
PPROM the PPV of delivery within a
week was enhanced. These ndings
further highlight the importance of GA
as an independent risk factor for latency.
Figure 2 shows a receiver operating
characteristic (ROC) curve comparing
the initial TVCL in women with AFI
>5 cm for predicting latency >7 days
with an area under the curve of 0.908.
According to this ROC curve, a TVCL
of 2.17 cm in the setting of an AFI >5
cm had a 79% sensitivity and 93%
specicity in predicting latency >7 days.
For practical clinical purposes and
for comparability with other studies we

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TABLE 5

Predicting delivery latency within 7 days following PPROM by each factor

Variable

Sensitivity

Specificity

PPV

NPV

TVCL
2 vs >2 cm (n 106)

26/51 51%

39/55 71%

26/42 62%

39/64 61%

AFI
5 vs >5 cm (n 105)

36/50 72%

29/55 53%

36/62 58%

29/43 67%

TVCL <2 vs >2 cm in women with AFI
5 cm (n 62)

15/36 42%

15/26 58%

15/26 58%

15/36 42%

TVCL <2 vs >2 cm in women with AFI >5 cm (n 43)

11/14 76%

24/29 83%

11/16 69%

24/27 89%

Prevalence of delivery <1 wk is 48%. Sensitivity, specificity, and predictive values were calculated for TVCL and AFI in relation to latency period of 7 d. PPV was defined as probability for delivery
within 7 d from test. NPV was defined as probability of remaining pregnant >7 d from test.
AFI, amniotic fluid index; NPV, negative predictive value; PPV, positive predictive value; TVCL, transvaginal cervical length.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

decided to use a TVCL of 2 cm. In

the setting of an AFI >5 cm, a TVCL of
2 cm had a 79% sensitivity and 83%
specicity.

C OMMENT
The ability to predict the timing of delivery is helpful to both the patient
and physician. To better counsel our
patients, we sought to determine
whether CL and amniotic uid volume
would independently predict latency in a
period of 7 days. Interventions such
as the administration of steroids, magnesium for neuroprotection, or the safe
transfer to a tertiary center can be optimized with this information.23 This information may be particularly important
in counseling women who would reject
in-hospital management19 or those who
leave against medical advice. Expectant
management in women with PPROM
improves neonatal survival by approximately 2% for each additional day of
in utero maturation, with the optimal
benet between 2-27 weeks.24
The relationship of CL on latency
following PPROM was demonstrated

in our cohort. We found a positive association between shorter CL and higher

delivery rates within 7 days, even after
adjustment for other confounding factors. Without knowledge of the results
of the TVCL or AFI approximately 48% of
women delivered within 7 days. With the
knowledge of a TVCL
2 cm or an AFI

5 cm this delivery probability changed
to 62% and 58%, respectively. For a better
understanding of delivery latency within 7
days common factors have been identied. This may have important clinical
implications as the optimal benets of
corticosteroid therapy are seen in women
who deliver within this time frame. Using
multiple logistic regression, we demonstrated that these factors are the presence
of uterine contractions after PPROM,
history of PPROM, history of preterm
birth, higher GA at TVCL (within 3 days
of admission), lower CL, and AFI
5 cm.
The knowledge of these additional risk
factors for a shorter latency may be
helpful in counseling and managing
women with PPROM.
The CL measurement by itself
does not have very high sensitivity or

specicity. But as shown by the

ROC curve the combination of an AFI >5
cm and a TVCL value of 2.1 cm improved
the sensitivity to 79% and specicity to
93%. However for practical purposes
of management and comparability to
other studies we chose a 2-cm cutoff
for analysis. Only 3 of 27 (11%) women
with a TVCL >2 cm and AFI >5 cm
delivered within 7 days. This indicates a
protective effect of both parameters
regardless of the GA. Although our
numbers are small, counseling can be
further rened using GA cutoff of 30
weeks. This knowledge helps one counsel
the patient of an improved likelihood of
remaining undelivered >7 days.
To our knowledge, our study is the
rst to demonstrate that together TVCL
and AFI are predictors of delivery at 7
days in a US population of mixed
ethnicity and insurance status who have
PPROM. Our ndings are in agreement
with 3 previous studies conducted
outside of the United States that examined the relationship between CL measurements and latency periods in
PPROM.13,16,17

TABLE 6

Predicting delivery latency within 7 days following PPROM by each factor 30 wks
Variable
TVCL
2 vs >2 cm (n 54)

Sensitivity

Specificity

PPV

NPV

7/16 44%

28/38 74%

7/17 41%

28/37 76%

13/16 81%

17/38 45%

13/34 38%

17/20 85%

TVCL <2 vs >2 cm in women with AFI
5 cm (n 34)

5/13 38%

14/21 67%

5/12 42%

14/22 64%

TVCL <2 vs >2 cm in women with AFI >5 cm (n 20)

2/3 67%

14/17 82%

2/5 40%

14/15 93%

AFI
5 vs >5 cm (n 54)

AFI, amniotic fluid index; NPV, negative predictive value; PPROM, preterm premature rupture of membranes; PPV, positive predictive value; TVCL, transvaginal cervical length.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

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TABLE 7

Predicting delivery latency within 7 days following PPROM by each factor >30 wks
Variable

Sensitivity

Specificity

PPV

NPV

TVCL
2 vs >2 cm (n 52)

19/35 54%

11/17 65%

19/25 76%

11/27 41%

AFI
5 vs >5 cm (n 51)

23/34 68%

12/17 71%

23/28 82%

12/23 52%

TVCL <2 vs >2 cm in women with AFI
5 cm (n 28)

10/23 43%

1/5 20%

10/14 71%

1/14 7%

TVCL <2 vs >2 cm in women with AFI >5 cm (n 23)

9/11 82%

10/12 83%

9/11 82%

10/12 83%

Prevalence of delivery <1 wk is 48%. Sensitivity, specificity, and predictive values were calculated for TVCL and AFI in relation to latency period of 7 days. PPV was defined as probability for delivery
within 7 d from test. NPV was defined as probability of remaining pregnant >7 d from test.
AFI, amniotic fluid index; NPV, negative predictive value; PPROM, preterm premature rupture of membranes; PPV, positive predictive value; TVCL, transvaginal cervical length.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

Tsoi et al17 examined 101 singleton

pregnancies between 24-36 weeks,
excluding women who delivered for
medical indications. This northern European population in the United
Kingdom and Germany was comprised
of 77% Caucasian, 12% Afro-Caribbean,
and 11% Asian with a median BMI of 25
kg/m2. Delivery within a week occurred
in 57% of those pregnancies. In our
population, 48% delivered spontaneously and for clinical indications within
the rst week. The exclusion of women
who delivered for clinical indications
and inclusion of a later GA by Tsoi et al17
might explain the difference in rates
of delivery within the week. In addition
our population was demographically
different, representing an urban US
population. Similar to our ndings, Tsoi
et al17 reported a positive relationship
of GA at PPROM and uterine contractions with an increased delivery risk.
Rizzo et al16 from Italy examined
92 singleton pregnancies with PPROM,
and demonstrated that a TVCL <2.0 cm,
or cervical funneling, was associated
with shorter latency, as was a low AFI at
admission.16 The primary outcome
measured was latency from admission to
delivery adjusted for covariates. Their
reported median time from admission
to delivery was 4.5 days, which was less
than the median of 8 days observed in
our population. Perhaps their performance of transabdominal amniocentesis
on all their patients was related to a
shorter latency.
The median latency period was also
shorter in the French population
described by Gire et al,13 as half of their

population delivered within 48 hours of

admission. They also reported that
TVCL
2.0 cm was associated with
signicantly shorter latency. Possible reasons for their shorter latency included a
much higher clinical chorioamnionitis
rate of 67%. They also did not permit
tocolysis and patients were actively delivered for an indication of anhydramnios,
in contrast to our management.
Carlan et al12 in Florida examined 45
women without nding a signicant
difference in the latency period using a
3-cm cutoff to characterize short CL.
Their lack of nding a difference may
have been due to a higher and less
discriminatory cutoff than a TVCL
2
cm.
Our ndings appear comparable to
previous studies that dened delivery
latency from admission or PPROM.
We dened latency from TVCL, which
was performed within 72 hours after
admission. We chose to use this time
period to control for the variable
amount of time reported from PPROM
to admission and time to the ascertainment of TVCL by a qualied sonographer. Of our cases, 64% had a TVCL
assessed within 24 hours of PPROM and
97% within 3 days of PPROM. We found
no signicant difference using the measure of latency from PPROM or from the
admission TVCL measurement. This
relationship was not specied in previous papers.
The strengths of our study include
a prospective, well-controlled study
design, utilizing multiple statistical approaches. The GA and diagnoses of
PPROM were carefully determined.

400.e7 American Journal of Obstetrics & Gynecology MARCH 2015

Biologic mechanisms such as genetic

variation and BMI3,25-27 have been proposed as explanations for disparities in
PPROM and preterm birth. Other than
Tsoi et al,17 none of the other referenced
studies provide information on ethnicities or BMI of the study population.
Our population consisted of a mixed
ethnicity, 55% Caucasian and 42% African American with a median BMI of
29, which differs from the northern
and southern European cohort of nonobese, white population and makes
our ndings more generalizable to a US
population. To our knowledge, this is the
most comprehensive prospective study
in the United States to examine the
clinical use of CL in predicting latency in

FIGURE 2

TVCL predicting delivery latency

at 7 days in women with AFI >5

AFI, amniotic fluid index; ROC, receiver operating characteristic;

TVCL, transvaginal cervical length.
Mehra. Cervical length and AFI: can it predict delivery latency PPROM? Am J Obstet Gynecol 2015.

CAOG Papers

ajog.org
PPROM. All TVCL measurements were
standardized and performed following
the CLEAR guidelines.22 Additionally,
we described the additive use of AFI in
providing the patient a rened risk of
delivery >7 days. Based on our ndings
one may be better able to counsel a patient on her risk of delivery, whether
spontaneous or indicated, from the
time of the admission TVCL.
Potential limitations in our study
include patients who were lost to
follow-up because they left after their
membranes resealed or against medical
advice. Our study population included
patients with PPROM who underwent
spontaneous labor and indicated delivery. By not excluding the patients
with indicated delivery we may have
limited the generalization of our ndings to women with spontaneous labor
only. However, a clinician cannot often
predict on admission who will ultimately be delivered spontaneously.
Although GA at PPROM is an important factor for latency we could not
substratify the results beyond the GA
cutoff of 30 weeks at PPROM due to
inadequate numbers. Adjunctive antibiotics are known to prolong delivery
at 7 days in women with PPROM.28,29
As all patients in our study received
adjunctive antibiotic therapy we were
unable to demonstrate the effects of
TVCL and AFI on prolonging latency in
the absence of antibiotics.
This study supports the predictive
ability of TVCL for latency and adds
predictive value of longer latency with
the combined use of TVCL >2 cm and
AFI >5 cm in women with PPROM.
We recommend the importance of
combining clinical factors into the risk
assessment of an individual with
PPROM. Based on our study we
recommend obtaining an initial TVCL
and AFI in women as soon as practical
after admission. Maternal symptoms of
uterine contractions and history of
PPROM and preterm birth should be
carefully assessed in the setting of
PPROM to help identify those women
at high risk of shorter latency. There
still remains a need to evaluate multiple
gestations, previable PPROM patients,
and combining ultrasound ndings

with biochemical markers to improve

prediction of latency. We recommend
further research to verify our results and
generate a clinically useful prediction
model for latency using multiple parameters in women with PPROM at
various GA substrata.
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