Home Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines
Article
Licensed
Unlicensed Requires Authentication

Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines

  • Marika De Vito , Jessica Cetraro , Giulia Capannolo , Sara Alameddine , Chiara Patelli , Francesco D’Antonio and Giuseppe Rizzo ORCID logo EMAIL logo
Published/Copyright: December 18, 2023
Journal of Perinatal Medicine
From the journal Journal of Perinatal Medicine Volume 52 Issue 3

Abstract

Objectives

Twin pregnancies are at increased risk of preterm birth (PTB) compared to singletons. Evaluation of cervical length (CL) represents the optimal tool to screen PTB in singleton. Conversely, there is less evidence on the use of CL in twins. Our aim was to evaluate the methodological quality and clinical heterogeneity of clinical practice guidelines (CPGs) on the CL application in twins using AGREE II methodology.

Methods

MEDLINE, Scopus, and websites of the main scientific societies were examined. The following aspects were evaluated: diagnostic accuracy of CL, optimal gestational age at assessment and interventions in twin pregnancies with reduced CL. The quality of the published CPGs was carried out using “The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)” tool. The quality of guideline was rated using a scoring system. Each considered item was evaluated by the reviewers on a seven-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). A cut-off >60 % identifies a CPGs as recommended.

Results

The AGREE II standardized domain scores for the first overall assessment had a mean of 74 %. The score was more than 60 % in the 66.6 % of CPGs analyzed indicating an agreement between the reviewers on recommending the use of these CPGs. A significant heterogeneity was found; there was no specific recommendation on CL assessment in about half of the published CPGs. There was also significant heterogeneity on the CL cut-off to prompt intervention.

Conclusions

Despite the fact that the AGREE II analysis showed that the majority of the included guidelines are of good quality, there was a significant heterogeneity among CPGs as regard as the indication, timing, and cut-off of CL in twins as well as in the indication of interventions.

Keywords: twin pregnancy; cervical length; preterm birth; transvaginal ultrasound; clinical practice guidelines
Corresponding author: Giuseppe Rizzo, MD, Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Viale Oxford 81, 00133 Rome, Italy, Phone: +39 06 2090 2750, E-mail:

  1. Research ethics: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contribution: All Authors provided a substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. Drafting the work or revising it critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing Interest: The authors state no conflict of interest.

  5. Research funding: None declared.

  6. Data availability: Data available on reasonable request.

References

1. Ochsenbein-Kölble, N. Twin pregnancies. Ultraschall der Med 2021;42:246–69. https://doi.org/10.1055/a-1344-4812.Search in Google Scholar PubMed

2. Khalil, A, Liu, B. Controversies in the management of twin pregnancy. Ultrasound Obstet Gynecol 2021;57:888–902. https://doi.org/10.1002/uog.22181.Search in Google Scholar PubMed

3. Roman, A, Ramirez, A, Fox, NS. Prevention of preterm birth in twin pregnancies. Am J Obstet Gynecol MFM 2022;4:100551. https://doi.org/10.1016/j.ajogmf.2021.100551.Search in Google Scholar PubMed

4. Berghella, V, Baxter, JK, Hendrix, NV. Cervical assessment by ultrasound for preventing preterm delivery. Cochrane Database Syst Rev 2013;CD007235. https://doi.org/10.1002/14651858.CD007235.pub3.Search in Google Scholar PubMed PubMed Central

5. Berghella, V, Saccone, G. Fetal fibronectin testing for prevention of preterm birth in singleton pregnancies with threatened preterm labor: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2016;215:431–8. https://doi.org/10.1016/j.ajog.2016.04.038.Search in Google Scholar PubMed

6. Wu, L, Lei, G, Tan, M. Transvaginal ultrasound cervical length for prediction of spontaneous labor at term: a protocol for systematic review and meta-analysis. Medicine (Baltim) 2020;99:e22237. https://doi.org/10.1097/md.0000000000022237.Search in Google Scholar

7. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics, Society for Maternal-Fetal Medicine. Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies: ACOG Practice Bulletin, Number 231. Obstet Gynecol 2021;13:e145–62.10.1097/AOG.0000000000004397Search in Google Scholar PubMed

8. Sentilhes, L, Sénat, MV, Ancel, PY, Azria, E, Benoist, G, Blanc, J, et al.. PY prevention of spontaneous preterm birth: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2017;210:217–24. https://doi.org/10.1016/j.ejogrb.2016.12.035.Search in Google Scholar PubMed

9. FIGO Working Group on Good Clinical Practice in Maternal-Fetal Medicine. Good clinical practice advice: management of twin pregnancy. Int J Gynaecol Obstet 2019;144:330–7. https://doi.org/10.1002/ijgo.12742.Search in Google Scholar PubMed

10. Morin, L, Lim, K. No. 260 – Ultrasound in twin pregnancies. J Obstet Gynaecol Can 2017;39:e398–411. https://doi.org/10.1016/j.jogc.2017.08.014.Search in Google Scholar PubMed

11. Eligibility criteria pertaining to the population & clinical areas, interventions, comparators, attributes of CPGs and recommendation characteristics (PICAR) statement: eligibility criteria pertaining to the population & clinical areas, interventions, comparators, attributes of CPGs and recommendation characteristics (PICAR) statement (figshare.com) [Accessed 31 May 2023].Search in Google Scholar

12. Management of monochorionic twin pregnancy: Green-top Guideline No. 51. BJOG 2017;124:e1–45.10.1111/1471-0528.14188Search in Google Scholar PubMed

13. Khalil, A, Rodgers, M, Baschat, A, Bhide, A, Gratacos, E, Hecher, K, et al.. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol 2016;47:247–63. https://doi.org/10.1002/uog.15821.Search in Google Scholar PubMed

14. von Kaisenberg, C, Klaritsch, P, Ochsenbein-Kölble, N, Hodel, ME, Nothacker, M, Hecher, K. Screening, management and delivery in twin pregnancy. Ultraschall der Med 2021;42:367–78. https://doi.org/10.1055/a-1248-8896.Search in Google Scholar PubMed

15. Società Italiana di Ecografia Ostetrico Ginecologica e Metodologie Biofisiche. National guidelines for ultrasound in obstetrics and gynaecology; 2021. https://www.sieog.it/wp-content/uploads/2021/11/Guidelines-for-obstetric_compressed.pdf [Accessed 31 may 2023].Search in Google Scholar

16. National Institute for Health and Care Excellence (NICE). Twin and triplet pregnancy; 2019. https://www.nice.org.uk/guidance/ng137/resources/twin-and-triplet-pregnancy-pdf-66141724389829 [Accessed 31 may 2023].Search in Google Scholar

17. The Royal Australian and New Zealand College of Obstetricians and Gynaecologist (RANZCOG). Management of monochorionic twin pregnancy; 2021. https://ranzcog.edu.au/wp-content/uploads/2022/05/Management-of-Monochorionic-Twin-Pregnancy.pdf [Accessed 31 May 2023].Search in Google Scholar

18. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and directorate of Strategy and Clinical Care, Health service executive. Clinical practice guideline management of multiple pregnancy; 2014. https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/clinical-practice-guideline-management-of-multiple-pregnancy.pdf [Accessed 31 May 2023].Search in Google Scholar

19. Fondazione Confalonieri Ragonese. Gestione della gravidanza multipla; 2016. https://www.sigo.it/wp-content/uploads/2016/03/Gestione-della-Gravidanza-Multipla.pdf [Accessed 31 May 2023].Search in Google Scholar

20. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) website: http://www.prisma-statement.org/?AspxAutoDetectCookieSupport=1 [Accessed 31 May 2023].Search in Google Scholar

21. Brouwers, MC, Kho, ME, Browman, GP, Burgers, JS, Cluzeau, F, Feder, G, et al.. AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ (Can Med Assoc J) 2010;18:E839–842. https://doi.org/10.1503/cmaj.090449.Search in Google Scholar PubMed PubMed Central

22. Brouwers, MC, Spithoff, K, Lavis, J, Kho, ME, Makarski, J, Florez, ID. What to do with all the AGREEs? The AGREE portfolio of tools to support the guideline enterprise. J Clin Epidemiol 2020;125:191–7. https://doi.org/10.1016/j.jclinepi.2020.05.025.Search in Google Scholar PubMed

23. Schmitz, T, Korb, D, Victoria, M, Seco, A, Santulli, P, Goffinet, F, et al.. Perinatal morbidity and mortality in dichorionic twin pregnancies according to the mode of conception. Am J Obstet Gynecol. 2022;226:440–2.10.1016/j.ajog.2021.10.034Search in Google Scholar PubMed

24. Fuchs, F, Senat, MV. Multiple gestations and preterm birth. Semin Fetal Neonatal Med. 2016;2:113–20.10.1016/j.siny.2015.12.010Search in Google Scholar PubMed

25. Homola, W, Florjański, J, Królak-Olejnik, B, Fuchs, T, Lachowska, M, Bek, W. The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies – 20 years of experience from one tertiary perinatal center. Taiwan J Obstet Gynecol 2019;58:482–6. https://doi.org/10.1016/j.tjog.2019.05.009.Search in Google Scholar PubMed

26. Duffy, CR. Multifetal gestations and associated perinatal risks. NeoReviews 2021;22:e734–46. https://doi.org/10.1542/neo.22-11-e734.Search in Google Scholar PubMed

27. Cheong-See, F, Schuit, E, Arroyo-Manzano, D, Khalil, A, Barrett, J, Joseph, KS, et al.. Global Obstetrics Network (GONet) Collaboration. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016;354:I 4353. https://doi.org/10.1136/bmj.i4353.Search in Google Scholar PubMed PubMed Central

28. Tsakiridis, I, Giouleka, S, Mamopoulos, A, Athanasiadis, A, Dagklis, T. Management of twin pregnancies: a comparative review of national and international guidelines. Obstet Gynecol Surv 2020;75:419–30. https://doi.org/10.1097/ogx.0000000000000803.Search in Google Scholar

29. FIGO Working Group on Good Clinical Practice in Maternal-Fetal Medicine. Good clinical practice advice: role of ultrasound in the management of twin pregnancy. Int J Gynaecol Obstet 2019;144:338–9. https://doi.org/10.1002/ijgo.12743.Search in Google Scholar PubMed

30. SMFM Research Committee, Grantz, KL, Kawakita, T, Lu, YL, Newman, R, Berghella, V, Caughey, A. SMFM special statement: state of the science on multifetal gestations: unique considerations and importance. Am J Obstet Gynecol. 2019;221:B2–B12, https://doi.org/10.1016/j.ajog.2019.04.013.Search in Google Scholar PubMed PubMed Central

31. Gardner, MO, Goldenberg, RL, Cliver, SP, Tucker, JM, Nelson, KG, Copper, RL. The origin and outcome of twin pregnancies. Obstet Gynecol 1995;85:553–57.10.1016/0029-7844(94)00455-MSearch in Google Scholar PubMed

32. Doyle, NM, Monga, M. Role of ultrasound in screening patients at risk for preterm delivery. Obstet Gynecol Clin N Am 2004;31:125–39. https://doi.org/10.1016/s0889-8545(03)00120-7.Search in Google Scholar

33. Pinton, A, Severac, F, Meyer, N, Akladios, CY, Gaudineau, A, Favre, R, et al.. A comparison of vaginal ultrasound and digital examination in predicting preterm delivery in women with threatened preterm labor: a cohort study. Acta Obstet Gynecol Scand 2017;96:447–53. https://doi.org/10.1111/aogs.13071.Search in Google Scholar PubMed

34. Romero, R, Conde-Agudelo, A, El-Refaie, W, Rode, L, Brizot, ML, Cetingoz, E, et al.. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. Ultrasound Obstet Gynecol 2017;49:303–14. https://doi.org/10.1002/uog.17397.Search in Google Scholar PubMed PubMed Central

35. Townsend, R, Khalil, A. Ultrasound surveillance in twin pregnancy: an update for practitioners. Ultrasound 2018;26:193–205. https://doi.org/10.1177/1742271x18794013.Search in Google Scholar

36. McIntosh, J, Feltovich, H, Berghella, V, Manuck, T. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol 2016;215:B2–7. https://doi.org/10.1016/j.ajog.2016.04.027.Search in Google Scholar PubMed

37. D’Antonio, F, Berghella, V, Di Mascio, D, Saccone, G, Sileo, F, Flacco, ME, et al.. Role of progesterone, cerclage and pessary in preventing preterm birth in twin pregnancies: a systematic review and network meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021;261:166–77. https://doi.org/10.1016/j.ejogrb.2021.04.023.Search in Google Scholar PubMed

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/jpm-2023-0262).

Received: 2023-06-26
Accepted: 2023-10-23
Published Online: 2023-12-18
Published in Print: 2024-03-25

© 2023 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Opinion Paper
  3. The importance of professional responsibility and fetal viability in the management of abortion
  4. Corner of Academy
  5. Multifetal pregnancy reductions and selective fetocide in a tertiary referral center – a retrospective cohort study
  6. Original Articles – Obstetrics
  7. Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines
  8. Determinants of prematurity in urban Indonesia: a meta-analysis
  9. Predictors of planned home birth before and during the COVID-19 pandemic
  10. Sensitivity of antenatal ultrasound in diagnosing posterior placenta accreta spectrum disorders
  11. The prognostic role of CRL discordance in first trimester ultrasound
  12. Evaluation of postpartum shock index in hypertensive diseases of pregnancy: a case-control study from a tertiary reference center
  13. Original Articles – Fetus
  14. Prenatal diagnosis of right aortic arch: associated anomalies and fetal prognosis according to different subtypes
  15. Fetal brain development in pregnancies complicated by gestational diabetes mellitus
  16. The association between parental SARS-CoV-2 infection in pregnancy and fetal growth restriction
  17. Subclinical cardiac impairments in fetuses conceived through assisted reproductive technology by speckle tracking echocardiography
  18. Original Articles – Neonates
  19. Coagulation assessment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infected pregnant women and their offspring by using rotational thromboelastometry (ROTEM)
  20. Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016–2021)
  21. Influence of donor characteristics on the milk donation volume and microbiological quality of donated human milk in first 3 years of work of the Croatian human milk bank-retrospective observational study
https://doi.org/10.1515/jpm-2023-0262
Keywords for this article
twin pregnancy; cervical length; preterm birth; transvaginal ultrasound; clinical practice guidelines

Articles in the same Issue

  1. Frontmatter
  2. Opinion Paper
  3. The importance of professional responsibility and fetal viability in the management of abortion
  4. Corner of Academy
  5. Multifetal pregnancy reductions and selective fetocide in a tertiary referral center – a retrospective cohort study
  6. Original Articles – Obstetrics
  7. Cervical length as a screening tool for preterm birth in twin pregnancies: a systematic review and critical evaluation of quality clinical practice guidelines
  8. Determinants of prematurity in urban Indonesia: a meta-analysis
  9. Predictors of planned home birth before and during the COVID-19 pandemic
  10. Sensitivity of antenatal ultrasound in diagnosing posterior placenta accreta spectrum disorders
  11. The prognostic role of CRL discordance in first trimester ultrasound
  12. Evaluation of postpartum shock index in hypertensive diseases of pregnancy: a case-control study from a tertiary reference center
  13. Original Articles – Fetus
  14. Prenatal diagnosis of right aortic arch: associated anomalies and fetal prognosis according to different subtypes
  15. Fetal brain development in pregnancies complicated by gestational diabetes mellitus
  16. The association between parental SARS-CoV-2 infection in pregnancy and fetal growth restriction
  17. Subclinical cardiac impairments in fetuses conceived through assisted reproductive technology by speckle tracking echocardiography
  18. Original Articles – Neonates
  19. Coagulation assessment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infected pregnant women and their offspring by using rotational thromboelastometry (ROTEM)
  20. Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016–2021)
  21. Influence of donor characteristics on the milk donation volume and microbiological quality of donated human milk in first 3 years of work of the Croatian human milk bank-retrospective observational study
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 16.9.2025 from https://www.degruyterbrill.com/document/doi/10.1515/jpm-2023-0262/html?lang=en
Scroll to top button