Systematic Review
Universal cervical length screening and risk of
spontaneous preterm birth: a systematic
review and meta-analysis
Kamran Hessami, MD; Elena D’Alberti, MD; Daniele Di Mascio, MD; Vincenzo Berghella, MD
Introduction
G lobally, preterm birth (PTB) is the
leading cause of neonatal morbid-
ity and mortality.1,2 In more than two-
thirds of cases, PTB occurs spontane-
ously (sPTB), following either preterm
labor (PTL) or preterm prelabor rup-
ture of membranes (PPROM).3 The
research of effective screening strategies
for sPTB in asymptomatic individuals is
of paramount importance because there
are evidence-based preventive strategies,
such as progesterone supplementation
and cervical cerclage, that can be offered
to patients at high risk.2,4−10
Transvaginal ultrasound (TVU) cer-
vical length (CL) evaluation has been
shown to be one of the main predictors
of sPTB,2 as cervical shortening is one
of the first asymptomatic before later
symptomatic PTL or PPROM.
Cite this article as: Hessami K, D’Alberti E, Mascio DD,
et al. Universal cervical length screening and risk of
spontaneous preterm birth: a systematic review and
meta-analysis. Am J Obstet Gynecol MFM
2024;6:101343.
From the Maternal Fetal Care Center, Boston
Children’s Hospital, Harvard Medical School,
Boston, MA (Dr Hessami); Department of
Maternal and Child Health and Urological
Sciences, Sapienza University of Rome, Rome,
Italy (Drs D’Alberti and Di Mascio); Division of
Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, Thomas Jefferson
University Hospital, Philadelphia, PA (Dr
Berghella).
Received January 24, 2024; revised February
20, 2024; accepted March 4, 2024.
K.H. and E.D.A. share first authorship.
The authors report no conflict of interest.
Corresponding author: Vincenzo Berghella,
MD. vincenzo.berghella@jefferson.edu
2589-9333/$36.00
© 2024 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.
ajogmf.2024.101343
OBJECTIVE: To evaluate the risk of spontaneous preterm birth with or without universal trans-
vaginal ultrasound cervical length screening at the time of midtrimester scan.
DATA SOURCES: Medline, Embase, ClinicalTrials.gov, and Web of Science were systemati-
cally searched from the inception of the databases to November 12, 2023, using combina-
tions of the relevant medical subject heading terms, key words, and word variants that were
considered suitable for the topic.
STUDY ELIGIBILITY CRITERIA: Studies including individuals with singleton gestations at 16
−25 weeks of gestation screened or not screened with universal transvaginal ultrasound cer-
vical length screening were considered eligible. Primary outcome was spontaneous preterm
birth <37 weeks; secondary outcomes were spontaneous preterm birth <34 and <32 weeks.
METHODS: Random effect head-to-head analyses were used to directly compare each out-
come, expressing the results as summary odds ratio and relative 95% confidence interval.
The quality of the included studies was independently assessed by 2 reviewers, using the
Newcastle-Ottawa scale for cohort studies and the Cochrane risk-of-bias tool for randomized
controlled studies. The study was registered on the prospective register of systematic reviews
database (PROSPERO) (registration number: CRD42022385325).
RESULTS: Eight studies, including 447,864 pregnancies, were included in the meta-analysis
(213,064 screened with transvaginal ultrasound cervical length and 234,800 unscreened). In
the overall analysis, universal transvaginal ultrasound cervical length did not significantly
decrease the spontaneous preterm birth rates <37 weeks (odds ratio, 0.92 [95% confidence
interval, 0.84−1.01], P=.07) and <34 weeks (odds ratio, 0.87 [95% confidence interval,
0.73−1.04], P=.12), but was significantly associated with a lower risk of spontaneous pre-
term birth <32 weeks (odds ratio, 0.84 [95% confidence interval, 0.76−0.94], P=.002). Indi-
viduals without a prior spontaneous preterm birth had a significantly lower risk of spontaneous
preterm birth <37 weeks (odds ratio, 0.88 [95% confidence interval, 0.79−0.97], P=.01)
and a lower trend of spontaneous preterm birth <32 weeks (odds ratio, 0.82 [95% confidence
interval, 0.66−1.01], P=.06) when screened with transvaginal ultrasound cervical length,
compared with no screening.
CONCLUSION: Universal transvaginal ultrasound cervical length screening usually <24 weeks
in singletons without a prior spontaneous preterm birth, is associated with a significant reduc-
tion in spontaneous preterm birth <37 weeks, compared with no screening.
Key words: cervical length, preterm birth, preterm labor, short cervix, transvaginal ultrasound,
universal screening
Although midtrimester TVU CL screen- universal TVU CL screening in such
ing is recommended by United States patients,2 despite the fact that this pop-
and international societies in individu- ulations of singletons without prior
als with singleton gestations and prior sPTB represents almost 90% of PTBs
sPTB,11−13 TVU CL screening in <34 weeks. Some of the main obstacles
asymptomatic individuals with no prior to TVU CL implementation are the
sPTB is not universally recommended, uncertainty of cost-effectiveness across
and only the International Society of the entire population and the lack of
Ultrasound in Obstetrics and Gynecol- conclusive results confirming a signifi-
ogy (ISUOG) guidelines recommend cant decrease in the risk of PTB by
May 2024 AJOG MFM 1
Systematic Review

AJOG MFM at a Glance Data extraction

A systematic literature search was per-
Why was this study conducted? formed by 2 independent authors (K.H.
The role of universal midtrimester transvaginal ultrasound (TVU) cervical and E.D.A.), and all abstracts were
length (CL) assessment is still a matter of debate. reviewed independently by 2 authors
Key findings (K.H. and E.D.A.). Agreement regard-
Universal TVU CL screening usually <24 weeks in singletons without a prior ing potential relevance was reached by
spontaneous preterm birth (SPTB) is associated with a significant reduction in consensus. Full-text copies of the rele-
SPTB <37 weeks, compared to no screening. vant papers were obtained, and relevant
data regarding study characteristics and
What does this add to what is known? pregnancy outcomes were extracted
Our findings support the implementation of a universal TVU CL screening at independently by the same 2 reviewers.
around 18−23 weeks for singletons without a prior SPTB. Inconsistencies were discussed by the
reviewers until a consensus was reached
or resolved by discussion with other
screening pregnant individuals without Study selection authors (D.D.M. and V.B.). For those
a prior sPTB.11−15 This systematic review aimed to evalu- articles in which the relevant informa-
Thus, this study aimed to ascertain ate the risk of sPTB with and without tion was not reported but the methodol-
the risk of sPTB with and without uni- universal TVU CL screening at the time ogy was such that the information
versal TVU CL screening at the time of of midtrimester scan, in particular in might have been recorded initially, the
midtrimester scan, in particular in indi- singletons without a prior sPTB. Selec- authors were contacted requesting the
viduals with singleton gestations and no tion criteria included either observa- data. Data abstraction was performed
prior sPTB. tional or interventional studies directly using a standardized collection form.
comparing the risk of sPTB between
pregnant individuals undergoing vs not Assessment of risk of bias
undergoing universal TVU CL in the Quality assessment of the observational
Materials and Methods midtrimester of pregnancy (screening studies included was performed using
Eligibility criteria, information vs not screening over the same period the Newcastle-Ottawa scale (NOS) for
sources, and search strategy or 2 different periods [after vs before cohort studies.22 According to the NOS,
This systematic review was performed the implementation of TVU CL]). Stud- each study is judged on 3 broad per-
according to an a-priori-designed pro- ies were excluded if designed as case spectives: selection of the study groups,
tocol recommended for systematic reports, case series, or review articles. comparability of the groups, and ascer-
reviews and meta-analyses.16−18 Med- Studies considering only overall PTB as tainment of the outcome of interest.
line, Embase and Cochrane databases outcome and cases with cervical cerc- Assessment of the selection of a study
were searched electronically until lage performed before screening includes evaluation of the representa-
November 2023 using the following key because of obstetric history were tiveness of the exposed cohort, selection
words: (“cervical length”[TIAB] OR excluded from the meta-analysis. Stud- of the nonexposed cohort, ascertain-
(“cervi*”[TIAB] AND (“ultrasound”[- ies using transabdominal ultrasound ment of the exposure, and demonstra-
TIAB] OR “sonograph*”[TIAB]))) (TAU) for CL screening were excluded, tion that the outcome of interest was
AND (“preterm delivery”[TIAB] OR even when TVU followed the TAU. not present at the start of the study.
“preterm birth”[TIAB] OR “prematur- The primary outcome was sPTB <37 Assessment of the comparability of the
e”[TIAB]) AND (“universal”[TIAB] OR weeks; secondary outcomes were sPTB study includes evaluation of the compa-
“routine”[TIAB] OR “worldwide”[- <34 weeks and sPTB <32 weeks. rability of cohorts on the basis of the
TIAB] OR “screening”[TIAB]). Because of the presence of 2 different design or analysis. Ascertainment of the
The search and selection criteria were design methods evaluating the effect of outcome of interest includes evaluation
restricted to the English language. Ref- TVU CL on the risk of sPTB, we of the type of assessment of the out-
erence lists of relevant articles and planned to perform 2 subgroup analy- come of interest and the length and ade-
reviews were hand-searched for addi- ses, 1 evaluating the screening program quacy of follow-up. According to the
tional reports. Preferred Reporting offered over the same period and 1 eval- NOS, a study can be awarded a maxi-
Items for Systematic Reviews and Meta- uating CL assessment over 2 different mum of one star for each numbered
analysis (PRISMA) guidelines were fol- periods, after and before the implemen- item within the selection and outcome
lowed.19−21 The study protocol for this tation of TVU CL screening. In addi- categories, and a maximum of 2 stars
systematic review was registered in the tion, we planned to perform a subgroup can be given for comparability. A score
prospective register of systematic analysis that considered only individu- of ≥7 was considered as high quality.
reviews database (PROSPERO) (regis- als without previous sPTB, which was In addition, we included a random-
tration number: CRD42022385325). our main aim. ized controlled trial (RCT) in the

2 AJOG MFM May 2024


analysis, and the quality assessment of
this study was performed using the
Cochrane risk-of-bias (RoB2) tool for
RCTs. It consists of 5 domains for
assessing bias in randomized trials: (1)
bias arising from the randomization
process, (2) bias because of deviations
from intended interventions, (3) bias
because of missing outcome data, (4)
bias in the measurement of the out-
come, and (5) bias in the selection of
the reported result. Each domain is
assessed using a set of signaling ques-
tions to evaluate the risk of bias for each
domain.23
Data synthesis
We used random effect head-to-head
analyses to directly compare each out-
come, expressing the results as sum-
mary odds ratio (OR) and relative 95%
confidence interval (CI). The statistical
heterogeneity was evaluated through
the heterogeneity measure (I2). For each
outcome, the total number of publica-
tions included in the meta-analyses was
<10. Thus, we were unable to assess
publication bias, either graphically,
through funnel plots, or formally,
through Egger’s regression asymmetry
FIGURE 1
PRISMA 2020 flow diagram
PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analysis. PTL, preterm labor; sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
test (in such cases, the power is too low
to distinguish chance from real asym-
metry).24 The statistical analysis was
conducted using Review Manager (Rev-
Man, version 5.4.1; The Cochrane Col-
laboration, London, United Kingdom).
Results
Study selection
A total of 1030 articles were retrieved.
Of those, 238 articles were excluded for
duplication. The remaining 792 studies
were screened for eligibility. Title and
abstract screening resulted in 13 poten-
tially eligible studies. After a full-text
assessment was conducted, 8 studies
met the inclusion criteria defined in our
methodology (Figure 1, Supplemental
Table 1). These 8 included studies com-
prised 447,864 patients at the mid-
trimester of the pregnancy; of these,
213,064 underwent TVU CL screening,
whereas 234,800 did not.
Study characteristics
The included studies were published
between 2014 and 2023 (Table 125−32).
Three studies were conducted in the
United States25−27; the others were in
India,28 Greece,29 France,30 Spain31 and
Systematic Review
Canada.32 Five studies were designed
retrospectively,26,27,29,31,32 2 studies
were prospective,25,30 and 1 was an
RCT.28 By design, all pregnancies were
singleton gestations. About half of the
population was represented by primipa-
rous individuals, whereas a prior sPTB
was present in 5% of pregnancies
(Table 125−32). TVU CL screening usu-
ally occurs between 18 and 23 weeks,
with a range from 16 to 25 weeks.
Vaginal progesterone was recom-
mended for cervical length ≤25 mm in
4 studies,28,30−32 ≤20 mm in 3 studies,25
−27
and ≤15 mm in 1 study.29 Cervical
cerclage was placed according to physi-
cal examination changes,26,27 and short
CL and history of sPTB.26 In 1 study,
cervical cerclage was placed for CL ≤15
mm; further cervical shortening
occurred during follow-up despite pro-
gesterone treatment,29 and in 1 study
for ≤10 mm (Table 2).25−32 In the
screened group, short cervix defined as
≤25 mm and ≤20 mm was found in
0.81% of cases and 0.78%, respectively.
Among screened individuals with a
diagnosis of short CL, about 62% of
patients overall received progesterone,
and 15% of patients with no previous
PTB received cerclage (Table 225−32).
The overall quality of the included
studies was moderate to high.25−28,30−32
Only 1 study had a NOS score <7
(Tables 3 and 4).25−27,29−32
Synthesis of results
Overall, the rate of sPTB <37 weeks was
not significantly different between the
TVU CL screened and unscreened pop-
ulation (OR, 0.92 [95% CI, 0.84−1.01],
P=.07, I2=52%) (Figure 2). Similarly,
there was no significant difference for
the rate of sPTB <34 weeks (OR, 0.87
[95% CI, 0.73−1.04], P=.12, I2=35%)
(Figure 3), whereas the rate of sPTB
<32 weeks was significantly lower in
the TVU CL screened group (OR, 0.84
[95% CI, 0.76−0.94], P=.002 I2=0%)
(Figure 4, Table 525−32).
When focusing on studies comparing
screening vs no screening for TVU CL
over the same period, we found no sig-
nificant difference either for the rate of
sPTB <37 weeks (OR, 0.91 [95% CI,
0.76−1.09], P=.30, I2=0%), <34 weeks
May 2024 AJOG MFM 3
4 AJOG MFM May 2024

Systematic Review
TABLE 1
Characteristics of the included studies
Eligibility criteria
Study Number Primiparous Prior PTB GA at TVU Definition of Outcomes of Variables for
Study (first author) Country design Screeninga,b Total population size of fetuses rate, n (%) rate, n (%) CL screening short CL, mm interest, wk adjustment
Orzechowski et al,25 United States P A 2171 (1569/602) SP 997 (45.9) Excluded 18 wk 0 d−23 wk 6 d ≤20 sPTB: <37, <34, and <32 Ethnicity, prior conization,
2014 and nulliparity
Temming et al,26 2016 United States R A 12,740 (10,871/1869) SP 4010 (31.5) 1209 (9.5) 17 wk 0 d−23 wk 6 d ≤20 sPTB: <37, <34, and <32 Ethnicity, smoking, and
history of PTB
Son et al,27 2016 United States R B 64,207 (17,609/46,598) SP 34,856 (54.3) Excluded 18 wk 0 d−23 6 d ≤20 PTB and sPTB: <37, <34, Ethnicity, BMI, and history
and <32 of the following: cervical
excision procedure,
smoking, chronic
hypertension, and
pregestational diabetes
Mishra et al,28 2018 India RP A 296 (147/149) SP 150 (50.67) Excluded 16 wk 0 d−23 6 d ≤25 sPTB: <37, and <32 NA
Souka et al,29 2019 Greece R B 15,298 (10,506/4792) SP 6860 (65.3)c 108 (1.0)c 20 wk 0 d−23 6 d ≤15 sPTB: <37, <34, and <32 NA
Figarella et al,30 2023 France Pd B 336,603 (165,524/171,079) SP 1595 (46)e 98 (2.8)e 16 wk 0 d−25 6 d ≤25 PTB and sPTB: <37 and Age, BMI, smoking
<32
Melchor Corcostegui et Spain R B 10,536 (4158/6378) SP NRf Excluded 19 wk 0 d−22 6 d ≤25 sPTB: <37, <34, and <32 NA
al,31 2023
Stratulat et al,32 2024 Canada R B 6013 (2680/3333) SP 2525 (42) 288 (4.8) 18 wk 0 d−23 6 d ≤25 PTB and sPTB: <37, <34, NA
and <32
Total − − A (n=3) 447,864 (213,064/234,800) SP 50,993/100,543 (50.7) 1703/32, 16 wk 0 d−25 6 d 4 studies ≤25 − −
B (n=5) 738 (5.2) 3 studies ≤20
1 study ≤15
BMI, body mass index; CL, cervical length; GA, gestational age; NA, not applicable; NR, not reported; P, prospective; PTB, preterm birth; R, retrospective; RP, randomized prospective; SP, Singleton pregnancies; sPTB, spontaneous preterm birth; tPTL, threatened pre-
term labor; TVU, transvaginal ultrasound; US, United States.
a
Screening assessment A: primary and secondary outcomes compared between screened and unscreened populations over the same periods; b Screening assessment B: primary and secondary outcomes compared between pregnant women over 2 different periods,
after and before TVU CL screening implementation; c Reported among screened women only; d Data from the French Programme de me dicalisation des syste mes d’information national database and the ECHOCOL (“echo”=“ultrasound” and “col”=“cervix” in French)
prospective cohort; e Reported for the ECHOCOL population only; f Reported only among women with tPTL.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
 TABLE 2
Preventive strategies after identifying short cervix during universal TVU CL screening
Short cervix treated with cerclage
Recommended Short cervix treated
Study (first author) vaginal PG Cervical cerclage Cervical pessary Short cervix, n/N (%) with PG, n/N (%) Overall No prior PTB
Orzechowski et al,25 2014 CL ≤20 mm Not indicated because of a low-risk Unspecified 17/1569 (1.1) 13/17 (76.5) 0/17 (0) 0/17 (0)
population without previous PTB
Temming et al,26 2016 CL ≤20 mm and no Those with a history of PTB and Unspecified 131/10,871 (1.2) 56/115 (48.7)a 35/115 (30.4)a NR
history of PTB CL≤25 mm or based on physical
examination
Son et al,27 2016 Recommended for CL Recommended when there is a cervical Not indicated 87/17609 (0.47) 40/87 (46) 31/87 (35.6) 31/87 (35.6)
≤20 mm dilatation on digital examination at <24
wk of gestation
Mishra et al,28 2018 Recommended for CL Unspecified Unspecified 2/147 (1.3) 1/2 (50) 1/2 (50) 1/2 (50)
≤25 mm
Souka et al,29 2019 CL ≤15 mm In the short-cervix (CL ≤15 mm) group, if Unspecified 113/10,506 (1.07) NR 14/113 (12.4) 12/113 (10.6)
further cervical shortening occurred
during follow-up despite PG treatment,
cervical cerclage was performed at the
discretion of the obstetrician
Figarella et al,30 2023 CL ≤25 mm Unspecified Unspecified 38/3468 (1.1)b 25/38 (65.8)b 1/38 (2.63) 1/38 (2.63)
Melchor Corcostegui et al, 2023
31
CL ≤25 mm Indicated for CL ≤10 mm Unspecified NR c
NRc NR NR
Stratulat et al,32 2024 Unspecified Unspecified Unspecified CL <25mm: 74/2680 (2.8) 74/74d 23/74 (31.1) 7/74 (9.45)
Total 4 studies: CL ≤25 mm Usually only for dilated cervix if no prior No report of use CL ≤25 mm (4 studies): 114/14,121 (0.81) 209/333 (62) 105/429 (24.4) 52/331 (15.7)
3 studies: ≤20 mm sPTB CL ≤20 mm (3 studies): 235/30,049 (0.78)
1 study: CL ≤15 mm CL ≤15 mm (1 study): 113/10,506 (1.07)
CL, cervical length; NR, not reported; PG, progesterone; PTB, preterm birth; sPTB, spontaneous preterm birth; tPTL, threatened preterm labor; TVU, transvaginal ultrasound.
a
Temming et al,26 2016 delivery outcome available only in 115/131 cases; b Reported in the ECHOCOL (“echo”=“ultrasound” and “col”=“cervix” in French) cohort study only; c Not reported for the whole population, only for those women presented with tPTL; d PG
among screened women was recommended in 98 women, whereas 74 women were diagnosed with a short cervix.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.

Systematic Review
May 2024 AJOG MFM
5
Systematic Review
TABLE 3
Quality assessment of the included studies according to the Newcastle-
Ottawa scale for cohort studies
Author
Orzechowski et al, 2014 25
Temming et al,26 2016
Son et al,27 2016
29
Souka et al, 2019
30
Figarella et al, 2023
Melchor Corcostegui et al,31 2023
Stratulat et al,32 2024
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
(OR, 0.78 [95% CI, 0.52-1.16], P=.22,
I2=22%), and <32 weeks (OR, 1.04
[95% CI, 0.40−2.73] P=.93, I2=0%)
(Supplemental Table 3).
When considering only studies com-
paring rates of sPTB after vs before a
policy of implementation of TVU CL,
there was no significant difference for
sPTB <37 weeks (OR, 0.92 [95% CI,
0.82−1.04], P=.20 I2=75%) and sPTB
<34 weeks (OR, 0.92 [95% CI, 0.73
−1.15], P=.46, I2=49%), whereas there
was a significant decrease of the rate of
sPTB <32 weeks after the implementa-
tion of TVU CL screening (OR, 0.84
[95% CI, 0.75−0.94], P=.003, I2=4%)
(Supplemental Table 4).
In the focus of our study, in the sub-
group of individuals with singleton ges-
tations and without a prior sPTB, there
was a significant reduction of sPTB <37
weeks (OR, 0.88 [95% CI, 0.79−0.97],
TABLE 4
The RoB2 tool for assessment of risk of bias in randomized controlled trials
D, domain; RoB2, Cochrane risk-of-bias.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
6 AJOG MFM May 2024
(Tables 525−32 and 6,25−28,31,32 Supple-
mentary Tables 3 and 4) showed that
TVU CL screening was associated
with about an 8% to 22% decrease in
Y Selection Comparability Outcome sPTB compared with no screening.
2014 $$$ $ $$$
Strengths and limitations
2016 $$$ $ $$$
Our study has several strengths. By
2016 $$$ $$ $$$ selecting studies carried out over the
2019 $$$ − $$$ last decade, we could consistently pro-
2023 $$$$ $ $$$
vide a preliminary estimate of the per-
formance of TVU CL as a routine
2023 $$$ $$ $$$ screening for sPTB. In general, the
2024 $$$ $$ $$$ included studies are of good quality and
have an overall low risk of bias, accord-
ing to the NOS scale and RoB2.
Moreover, because of the extensive sys-
tematic literature search, this is the first
P=.01, I2=16%; Figure 5). No significant study that reports on a notable number
differences were found for sPTB <34 of patients undergone a universal mid-
weeks (OR, 0.85 [95% CI, 0.68−1.06], trimester TVU CL screening
P=.14, I2=37%; Figure 6), and for sPTB (n=213,064). Another strength is that
<32 weeks (OR, 0.82 [95% CI, 0.66 all studies used only TVU as the
−1.01], P=.06, I2=0%; Figure 7) method for CL screening.
(Table 625−28,31,32). Another strength is the rigorous
methodology of our statistical analysis.
Comment In addition to the main results obtained
Main findings from the overall study population, we
The findings from this systematic performed 2 subgroup analyses to assess
review showed that, overall, universal results from different designs and meth-
midtrimester TVU CL screening signifi- ods. In one, universal TVU CL was
cantly decreased the risk of sPTB <32 compared with a nonscreening group
weeks compared with unscreened over the same period; in the other, it
patients in an unselected risk popula- was compared with the period before its
tion, whereas when performed in single- implementation. Once the similarities
ton individuals without prior sPTB, between the data of subgroups and the
which was the focus of our study, TVU overall population were assessed, the
CL screening was associated with a sig- feasibility of the analysis, including all
nificant reduction in sPTB <37 weeks. the studies, was effectively established.
Interestingly, 11 out of 12 analyses Furthermore, the subgroup analysis we

FIGURE 2
Forest plot for the risk of sPTB <37 weeks
sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
FIGURE 3
Forest plot for the risk of sPTB <34 weeks
sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
FIGURE 4
Forest plot for the risk of sPTB <32 weeks
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
were focused on had a considerable
sample of patients with singleton gesta-
tions and without prior sPTB screened
with TVU CL in the midtrimester
(n=92,821).
Moreover, considering as outcomes
the occurrence of sPTB <37, <34, and
<32 weeks, we provided a more accu-
rate impact of TVU CL on the sponta-
neous onset of PTB, reducing the bias
that iatrogenic PTB inclusion might
have induced.
In addition, we acknowledge our lim-
itations. The individual studies differ
somewhat in the CL cutoff to define a
short cervix requiring preventive strate-
gies, such as vaginal progesterone or
cerclage. For instance, 3 studies used a
CL cutoff of 25 mm, 3 studies used
20 mm, and 1 study used 15 mm. This
Systematic Review
reflects different recommendations
among national guidelines and local
protocols, but universal screening might
have had an increased effect in reducing
the rate of sPTB if all the included stud-
ies had considered CL 25 mm as a cutoff
to define a short cervix.2 Thus, out-
comes in the group of individuals
screened with TVU CL might have been
influenced by different preventive strat-
egies adopted after identifying a short
cervix. Moreover, only 60% of patients
received progesterone after a diagnosis
of a short cervix, underestimating the
potential benefit of TVU CL implemen-
tation.
Another limitation is that, in some of
the included studies, individuals under-
going TVU CL were more likely to have
a prior cervical excision procedure and
to have other risk factors for sPTB.25
−27,30
After adjusting for these factors,
aORs were significant for PTB <37,
<34, and <32 weeks in the study with
the most prominent population.27
Comparison with existing literature
This meta-analysis demonstrated that
universal TVU CL screening detected
short CL, defined mostly as ≤25 or
≤20 mm and detected in nearly 1% of
patients with singleton pregnancies, and
was associated with a significant risk
reduction of sPTB <32 weeks, when
prematurity most likely leads to worse
perinatal and neonatal outcomes,33,34
with an overall reduction of 16% in the
subset of patients screening with TVU
CL, than those not undergoing CL
screening.
Although there is a consensus for
TVU CL screening in singleton preg-
nancies with prior sPTB, the role of uni-
versal midtrimester TVU CL
assessment in singleton gestations with-
out a prior sPTB is still a matter of
debate, with controversial recommen-
dations provided from both national
and international guidelines (Supple-
mentary Table 2). However, our results
showed that there was a significant
reduction of 12% for sPTB <37 weeks
and a lower trend of severe PTBs
(namely <32 weeks) among patients
with singleton gestations and no prior
PTB screened with TVU CL.
May 2024 AJOG MFM 7
8 AJOG MFM May 2024

Systematic Review
TABLE 5
Results for primary and secondary outcomes
Melchor
Stratulat Corcostegui Figarella Souka Mishra Son Temming Orzechowski
et al,32 2024 et al,31 2023 et al,30 2023 et al,29 2019 et al,28 2018 et al,27 2016 et al,26 2016 et al,25 2014 Total OR (95% CI) I2 P value
sPTB <37 wk 105/2441 (4.3) 77/4158 (1.85) 2944/165,524 (1.7) NA 15/147 (10.2) 701/17,609 (3.98) 639/9731(6.56) 65/1569 (4.14) 4546/201,179 (2.26) 0.92 (0.84−1.01) 52% .07
vs vs vs vs vs vs vs vs
140/3112 (4.5) 105/6378 (1.64) 3179/171,079 (1.85)a 12/149 (8.1) 2258/46,598 (4.85) 121/1661(7.28) 28/602 (4.65) 5843/229,579 (2.54)
sPTB <34 wk 32/2441 35/4158 (0.84) NA 89/7116 (1.25) NA 176/17609 (1.00) 207/9731 (2.13) 24/1569 (1.53) 563/42,624 (1.32) 0.87 (0.73−1.04) 35% .12
vs vs vs vs vs vs vs
33/3112 (1.1) 44/6378 (0.68) 73/4792 (1.52) 594/46,598 (1.3) 50/1661 (3.01) 8/602 (1.33) 729/58,351 (1.27)
sPTB <32 wk 19/2441 (0.78) 12/4158 (0.28) 423/165,524 (0.25) 36/7116 (0.51) 2/147 (1.36) 94/17,609 (0.53) NA 12/1569 (0.76) 598/198,564 (0.30) 0.84 (0.76−0.94) 0% .002
vs vs vs vs vs vs vs vs
20/3112 (0.6) 13/6378 (0.20) 513/171,079 (0.30)a 33/4792 (0.69) 1/149 (0.7) 328/46,598 (0.58) 5/602 (0.83) 913/232,720 (0.39)
Presented values are shown as n/N (%).
CI, confidence interval; NA, not applicable; OR, odds ratio; sPTB, spontaneous preterm birth
a
Figarella et al,30 2023 provided data as rates of PTB <37 wk, broken down by causes of PTB. To assess sPTB only, we considered only cases of preterm labor because it is not clear whether pPROM received induction or if an sPTB occurred; thus, considering preterm
prelabor rupture of membranes (PPROM) could also have biased our analysis, particularly for PTB <37 weeks. The authors requested the total number of PPROM cases that received induction; we are waiting for a reply.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.

TABLE 6
Subgroup analysis for sPTB in individuals without a history of sPTB
Melchor
Corcostegui
Subgroup 32
Stratulat et al, 2024 et al,31 2023 Mishra et al,28 2018 Son et al,27 2016 Temming et al,26 2016 Orzechowski et al,25 2014 Total OR (95% CI) I2 P value
sPTB <37 wk 79/2314 (3.4) 77/4158 (1.85) 15/147 (10.2) 701/17,609 (3.98) 507/8837 (5.7) 65/1569 (4.14) 1444/34,634 (4.16) 0.88 (0.79−0.97) 16% .01
vs vs vs vs vs vs vs
110/2969 (3.7) 105/6378 (1.64) 12/149 (8.1) 2258/46,598 (4.85) 96/1491 (6.4) 28/602 (4.65) 2609/58,187 (4.5)
sPTB <34 wk 18/2314 (0.8) 35/4158 (0.84) NA 176/17,609 (1.00) 162/8837 (1.8) 24/1569 (1.53) 415/34,487 (1.20) 0.85 (0.68−1.06) 37% .14
vs vs vs vs vs vs
23/2969 (0.8) 44/6378 0-68) 594/46,598 (1.05) 42/1491 (2.8) 8/602 (1.33) 711/58,038 (1.26)
sPTB <32 wk 10/2314 (0.4) 12/4158 (0.28) 2/147 (1.36) 94/17,609 (0.53) NA 12/1569 (0.76) 130/25,797 (0.50) 0.82 (0.66−1.01) 0% .06
vs vs vs vs vs vs
13/2969 (0.4) 13/6378 (0.20) 1/149 (0.7) 328/46,598 (0.58) 5/602 (0.83) 360/56,696 (0.63)
Presented values are shown as n/N (%).
CI, confidence interval; NA, not applicable; OR, odds ratio; sPTB, spontaneous preterm birth
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.

FIGURE 5
Forest plot for the risk of sPTB <37 weeks among women without a history
of sPTB
sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
FIGURE 6
Forest plot for the risk of sPTB <34 weeks among women without a history
of sPTB
sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
FIGURE 7
Forest plot for the risk of sPTB <32 weeks among women without a history
of sPTB
sPTB, spontaneous preterm birth.
Hessami. Universal cervical length screening and risk of preterm birth. Am J Obstet Gynecol MFM 2024.
TVU CL fulfills all the conditions
required by World Health Organization
for a successful screening, as it clearly
detects individuals at risk for sPTB, and
there is an effective preventive strategy
with vaginal progesterone once a short
cervix is diagnosed that is also cost-
effective. However, those opposing uni-
versal screening claim that the epidemi-
ology of PTB is such that the screening
will not appreciably reduce its preva-
lence in the population.35
A previous Cochrane meta-analysis
published in 2019 failed to show enough
Systematic Review
evidence to recommend routine univer-
sal TVU CL screening, mostly because
of the limitations inherent to the
included studies and the high heteroge-
neity of the study population that could
considerably affect the strength of the
results.36 In contrast to the 2019
Cochrane meta-analysis, we showed a
significant reduction of sPTB <32
weeks in an unselected risk population
and a significant 12% decrease in sPTB
in singletons without a prior sPTB
screened with TVU CL.
Conclusions and Implications
Universal midtrimester TVU CL
screening in asymptomatic singleton
gestations, of which >95% were without
a prior sPTB, was associated with a sig-
nificant reduction in the risk of sPTB
<32 weeks; moreover, universal TVU
CL screening usually <24 weeks, specifi-
cally in asymptomatic singletons with-
out a prior SPTB, which was the focus
of our study, was associated with a sig-
nificant reduction in sPTB <37 weeks,
compared with no screening. These
results occurred despite the facts that
patients with TVU CL screening were at
higher risk for sPTB, that CL was
defined as short as 25 mm in only 3 out
of 8 studies, and that only 60% of those
with a short CL were treated with vagi-
nal progesterone as currently recom-
mended. Given these results, our
systematic review supports guidelines,
such as those by ISUOG,2 that recom-
mend the implementation of a universal
TVU CL in asymptomatic singletons
without a prior sPTB at around 18−22
weeks, the time of the anatomy scan.
Well-designed RCTs with an adequate
sample size can also better elucidate this
issue. TVU CL screening between 16
and 23 weeks is already recommended
by the American College of Obstetricians
and Gynecologists, Society for Maternal-
Fetal Medicine, and other societies for
asymptomatic singletons with prior
sPTB11,12 (Supplemental Table 2). &
CRediT authorship contribution
statement
Kamran Hessami: Conceptualization.
Elena D’Alberti: Writing − original
draft. Daniele Di Mascio: Writing −
May 2024 AJOG MFM 9
Systematic Review
review & editing, Supervision. Vin-
cenzo Berghella: Writing − review &
editing, Supervision. &
Supplementary materials
Supplementary material associated with
this article can be found in the online ver-
sion at doi:10.1016/j.ajogmf.2024.101343.
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