PRENATAL DIAGNOSIS

Prenat Diagn 2011; 31: 84–89.

Published online 28 December 2010 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/pd.2640

Prediction of spontaneous preterm delivery

from endocervical length at 11 to 13 weeks
Elena Greco1,2 , Annabel Lange1,2 , Fred Ushakov1 , Jesus Rodriguez Calvo1,2 and Kypros H. Nicolaides1,2 *
1
Department of Fetal Medicine, University College Hospital, London, UK
2
Harris Birthright Research Centre of Fetal Medicine, King’s College Hospital, London, UK

Objective To define the potential value of endocervical length at 11 to 13 weeks’ gestation in the prediction
of spontaneous early delivery.

Method The lengths of the endocervix and cervico–isthmic complex were measured by transvaginal
ultrasound at 11 to 13 weeks in singleton pregnancies, including 1492 that subsequently delivered after
34 weeks and 16 (1.1%) who had spontaneous delivery before 34 weeks. In 1320 of the cases, the measurements
were repeated at 20 to 24 weeks.

Results There were significant associations in the length of the endocervix and cervico-isthmic complex
between 11 to 13 and 20 to 24 weeks (r = 0.548, p < 0.0001 and r = 0.194, p < 0.0001), and the respective
median lengths were 32.4 and 32.2 mm for the endocervix and 45.3 and 40.4 mm for the cervico–isthmic
complex. At 11 to 13 weeks in the early delivery group, compared to unaffected pregnancies, the median
endocervical length was shorter (27.5 vs 32.5 mm, p < 0.0001), but there was no significant difference in the
length of the cervico–isthmic complex (41.4 vs 45.4 mm, p = 0.054).

Conclusion In the measurement of cervical length, the endocervix should be distinguished from the isthmus.
The endocervical length at 11 to 13 weeks is shorter in pregnancies resulting in spontaneous delivery before
34 weeks than in those delivering after 34 weeks. Copyright  2010 John Wiley & Sons, Ltd.
KEY WORDS: first-trimester screening; preterm delivery; cervical length; endocervix; isthmus; transvaginal
ultrasound

INTRODUCTION cerclage. This reduces the risk of spontaneous early

preterm delivery by about 40% in women who had a
Preterm birth is responsible for 75% of all neonatal previous preterm birth or second-trimester loss but not
deaths and over half the neurological handicap in in those without such history (To et al., 2004; Berghella
children [McCormick, 1985; Centre for Maternal and et al., 2005).
Child Enquiries (CMACE), 2010]. Although all births The disadvantages of measuring cervical length at
before 37 weeks’ gestation are defined as preterm, the 20 to 24 weeks are first, inevitable failure to identify
vast majority of mortality and morbidity relates to cervical incompetence leading to miscarriage before this
early delivery before 34 weeks. Although improvements gestation and second, the effectiveness of prophylactic
in neonatal care have led to higher survival of very administration of progesterone or cervical cerclage may
premature infants, a major impact on the associated be inversely related to the gestation at which treatment
mortality and morbidity will only be achieved through is initiated. Certainly in women who had a previous
the development of a sensitive method to identify preterm birth or second-trimester loss, cervical cerclage
women at high risk of preterm delivery and an effective is either carried out electively in the first trimester
strategy for the prevention of this complication. or it is reserved for those where serial scans, starting
The risk of spontaneous preterm birth is inversely from the first-trimester, demonstrate cervical shortening
related to cervical length measured by transvaginal (Althuisius et al., 2000).
sonography at 20 to 24 weeks’ gestation (Iams et al., Several studies reported that the measurement of
1996; Heath et al., 1998; Kagan et al., 2006; To et al., cervical length in the first trimester is not predictive of
2006; Celik et al., 2008). In women with a short
preterm delivery (Zorzoli et al., 1994; Hasegawa et al.,
cervix, administration of progesterone reduces the risk
of spontaneous early preterm delivery by about 40% 1996; Carvalho et al., 2003; Conoscenti et al., 2003;
(Fonseca et al., 2007). However, progesterone is not as Ozdemir et al., 2007). The mean or median cervical
effective in women with cervical length below 12 mm length in these studies (40–44 mm) was considerably
as in those with a length of 12 to 15 mm. An alternative longer than in the second trimester. It is possible that
treatment for women with a short cervix is cervical cervical shortening in cases of preterm delivery is not
apparent in the first trimester because it occurs after
*Correspondence to: Kypros H. Nicolaides, Harris Birthright
16 weeks (Berghella et al., 2003). Alternatively, preterm
Research Centre for Fetal Medicine, King’s College Hospital, delivery is associated with short cervix in the first
London SE5 9RS, UK. E-mail: kypros@fetalmedicine.com trimester but this has not been recognised because

Copyright  2010 John Wiley & Sons, Ltd. Received: 10 August 2010
Revised: 3 September 2010
Accepted: 5 September 2010
Published online: 28 December 2010
 CERVICAL LENGTH AND PRETERM DELIVERY 85

in the measurement of cervical length sonographers is blurred and then advanced gently until the image is
inadvertently include the uterine isthmus. restored without exerting undue pressure on the cervix.
The aim of this study was to define and standardise Fourth, the settings of the ultrasound machine are altered
the technique for the measurement of cervical length at to obtain the widest viewing angle and the magnification
11 to 13 weeks and to determine the potential value of is increased so that most of the screen is occupied by
this measurement in the prediction of spontaneous early the tissues between the external cervical os at one end
preterm birth. of the picture and gestational sac at the other end. Fifth,
callipers are used to measure in sequence the linear dis-
tance between the two ends of the glandular area around
METHODS the endocervical canal and the shortest distance between
the glandular area and the gestational sac (isthmus).
The data for this study were derived from prospective All the operators performing the scans had received
screening for fetal abnormalities and pregnancy com- extensive training and had all passed a practical exam-
plications in women attending for their routine first ination administered by an expert to demonstrate their
hospital visit in pregnancy at University College Hos- competence in the technique. In addition, all ultrasound
pital, London, UK. In this visit, which is held at 11+0 to images for every study subject were reviewed by a
13+6 weeks of gestation, we record maternal character- single investigator who was unaware of the outcome
istics and medical history and perform transabdominal of pregnancy, to ensure that measurements were made
and transvaginal sonography to (1) determine gestational appropriately and consistently.
age from the measurement of the fetal crown-rump
length, (2) diagnose any major fetal abnormalities and Diagnosis of spontaneous early preterm
(3) measure fetal nuchal translucency thickness as part delivery
of screening for chromosomal abnormalities (Robinson
and Fleming, 1975; Snijders et al., 1998). The transvagi-
nal scan includes the measurement of cervical length Data on pregnancy outcome were obtained from the
and if this is less than 15 mm the women who are at maternity computerised records or the general medical
high risk for preterm delivery are referred to a specialist practitioners of the women and were also recorded
clinic. However, in this study, none of the patients had in our database. The obstetric records of all patients
such a short cervix. In our hospital, all women at 20 delivering before 34 weeks were examined to determine
to 24 weeks of gestation are offered another ultrasound whether the preterm delivery was medically indicated or
scan for the diagnosis of fetal abnormalities, assessment spontaneous. The latter included those with spontaneous
of fetal growth and transvaginal measurement of cervical onset of labour and those with preterm pre-labour
length. rupture of membranes.
The inclusion criteria for this study were singleton
pregnancies with the measurement of cervical length at Statistical analysis
11 to 13 weeks and delivery at or after 24 weeks’ ges-
tation. We excluded pregnancies ending in termination, Comparison between the outcome groups was by
miscarriage or fetal death before 24 weeks and those Mann–Whitney U -test for continuous variables and χ 2 -
with iatrogenic delivery before 34 weeks. test or Fisher’s exact test for categorical variables. The
significance of difference in endocervical length and cer-
Measurement of endocervical and isthmic vico–isthmic complex length (endocervical plus isthmic
length length) in the spontaneous early delivery and unaffected
groups was determined. Regression analysis was used to
We have observed that in the majority of women under- examine the association in the measurements between 11
going cervical assessment before the development of the to 13 weeks and those at 20 to 24 weeks for the length of
lower uterine segment, there is a persistent myometrial both the endocervix and the cervico–isthmic complex.
thickening between the endocervix and the gestational The statistical software package SPSS 16.0 (SPSS
sac (Figure 1). This thickening is likely to represent the Inc., Chicago, IL, USA) was used for data analyses.
isthmus rather than a contraction. Consequently, in the
measurement of cervical length, which for the purpose
of clarity we define as endocervical length, we undertake RESULTS
the following steps. First, the women are asked to empty
their bladder and are placed in the dorsal lithotomy During the study period (July 2009 to February 2010),
position. Second, the vaginal transducer (2.7–9.3 MHz) we measured the cervical length at 11 to 13 weeks
is introduced in the anterior fornix of the vagina and in 1548 singleton pregnancies. We excluded 40 cases
adjusted to obtain a sagittal view of the entire length of because the pregnancies resulted in miscarriage or
the cervical canal, which may be either translucent or termination (n = 34) or there was iatrogenic delivery at
echodense. The canal is bordered by the endocervical 24 to 33 weeks (n = 6), for preeclampsia in 4, maternal
mucosa, which is usually of decreased but occasionally cerebral haemorrhage in 1 and bleeding from a placenta
of increased echogenicity compared to the surrounding previa in 1. In the 1508 cases included in the study, 16
tissues. Third, the probe is withdrawn until the image (1.1%) had spontaneous delivery before 34 weeks and

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2011; 31: 84–89.
DOI: 10.1002/pd
86 E. GRECO et al.

Figure 1—Ultrasound pictures illustrating the measurement of the length of the endocervix (A to B) and the isthmus (B to C). In one picture,
the placenta (P) overlies the opening of the isthmus into the uterine cavity

1492 delivered after 34 weeks. The cervical length was was significantly shorter, but there was no significant
also measured at 20 to 24 weeks in 1320 of the cases, difference in the length of the cervico–isthmic complex
including 12 of those with subsequent spontaneous (Figure 3 and Table 2).
delivery before 34 weeks. The endocervical length was below the median in
The maternal characteristics and obstetric history in all 16 cases with spontaneous early delivery. The
the screened population are summarised in Table 1. In endocervical length was below 25 mm in 6 (37.5%)
the group with spontaneous early delivery, there was a of the early preterm delivery group and 42 (2.8%) of
higher prevalence of women of African racial origin and the unaffected pregnancies. The respective values for
women with a previous miscarriage at 16 to 23 weeks endocervical length 25 to 29.9 mm and ≥30 mm were
or spontaneous delivery at 24 to 33 weeks. 9 (56.3%) versus 367 (24.6%) and 1 (6.3%) versus
1083 (72.6%). Therefore, the rate of spontaneous early
Findings at 11 to 13 weeks delivery decreased with endocervical length from 12.5%
(6 of 48) for length below 25 mm to 2.4% (9 of 376)
for length of 25 to 29.9 mm and 0.1% (1 of 1084) for
The maternal and pregnancy characteristics are presented length of ≥30 mm (χ 2 -test, p < 0.0001).
in Table 1.
The median endocervical length at 11 to 13 weeks was
32.4 mm (5th centile 25.6 mm, 95th centile 40.2 mm) Relation of findings at 11 to 13 weeks
and median length of the cervico–isthmic complex was and 20 to 24 weeks
45.3 mm (5th centile 30.9 mm, 95th centile 65.3 mm)
(Figures 2 and 3). The median length of the isthmus In the 1320 cases examined at 20 to 24 weeks, the
was 13.8 (range 0–49.4) mm and it was above 5 mm in median endocervical length was 32.2 mm (5th centile
1287 (85.3%) of the 1508 cases. 24.6 mm, 95th centile 40.2 mm) and median length of
In the spontaneous early delivery group, compared to the cervico–isthmic complex was 40.4 mm (5th centile
unaffected pregnancies, the median endocervical length 26.1 mm, 95th centile 60.6 mm). The median length

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2011; 31: 84–89.
DOI: 10.1002/pd
 CERVICAL LENGTH AND PRETERM DELIVERY 87
Table 1—Maternal characteristics and obstetric history in the screened population

Characteristics Delivery ≥34 weeks (n = 1492) Early preterm (n = 16)

Maternal age in years, median (IQR) 32.5 (29.3–35.6) 33.2 (29.7–35.9)
Maternal weight, median (IQR) 63.0 (57.2–70.7) 61.8 (55.5–81.0)
Maternal height in cm, median (IQR) 165 (160–170) 163 (156–167)
Racial origin
Caucasian, n (%) 1096 (73.5) 10 (62.5)
African, n (%) 126 (8.4) 4 (25.0)∗
South Asian, n (%) 149 (10.0) 1 6.3)
East Asian, n (%) 91 (6.1) 0
Mixed, n (%) 30 (2.0) 1 (6.3)
Cigarette smoker, n (%) 32 (2.1) 0
Conception
Spontaneous, n (%) 1,402 (94.0) 16.0 (100)
Ovulation drugs, n (%) 90 (6.0) 0
Obstetric history
Nulliparous—no pregnancy at >16 weeks, n (%) 937 (62.8) 9 (56.3)
Nulliparous—miscarriage at 16 to 23 weeks, n (%) 22 (15) 2 (12.5)∗
Parous—preterm delivery 24 to 33 weeks, n (%) 14 (0.9) 2 (12.5)∗
Parous—delivery >34 weeks, n (%) 519 (34.8) 3 (18.8)

Comparisons between groups (χ 2 -test and Fisher’s exact test for categorical variables and Mann–Whitney U -test for continuous variables).
∗ p < 0.05.

Figure 2—Distribution of endocervical length at 11 to 13 weeks

(histograms and overlying curve). The curve on the right is the
distribution of length of the cervico–isthmic complex

of the isthmus was 7.8 (range 0–51.0) mm and it was

above 5 mm in 862 (65.3%) cases.
There was a significant association in the measure-
ments between 11 and 13 weeks and those at 20
to 24 weeks for the length of the endocervix (r =
0.548, p < 0.0001; Figure 4), isthmus (r = 0.089, p =
0.001) and the cervico–isthmic complex (r = 0.194,
p < 0.0001).
In the spontaneous early delivery group, compared Figure 3—Reference range (50th, 5th and 95th centiles) and indi-
vidual measurements in women with subsequent spontaneous deliv-
to unaffected pregnancies, the length of both the endo- ery before 34 weeks (closed circles) and those delivering at or after
cervix and the cervico–isthmic complex was signifi- 34 weeks (open circles)
cantly shorter (Table 2).

In the measurement of cervical length, we adhered to

DISCUSSION the criteria suggested by Sonek and Shellhaas (1998).
These authors highlighted the importance of includ-
This study has demonstrated that (1) in the measurement ing in the measurement only the portion of the cervix
of cervical length it is important to distinguish between where the canal is bordered by the endocervical mucosa.
the endocervix and the isthmus and (2) the endocervical Anatomical studies have demonstrated that during the
length at 11 to 13 weeks is shorter in pregnancies early stages of pregnancy there is marked hypertrophy
resulting in spontaneous delivery before 34 weeks than of the isthmic muscle (Danforth, 1947). In the second
in those delivering after 34 weeks. and third trimesters, the isthmus undergoes a gradual

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2011; 31: 84–89.
DOI: 10.1002/pd
88 E. GRECO et al.

Table 2—Comparison of the length of the endocervix and cervico–isthmic complex at 11 to 13 weeks and 20 to 24 weeks in
women with spontaneous delivery before 34 weeks’ gestation and those delivering at or after 34 weeks

Variables Delivery ≥34 weeks Delivery <34 weeks p

11 to 13 weeks
Endocervical length, median (IQR) 32.5 (29.5–35.6) 27.5 (24.0–28.6) <0.0001
Cervico–isthmic length, median (IQR) 45.4 (39.0–53.1) 41.4 (34.8–45.8) 0.054
20 to 24 weeks
Endocervical length, median (IQR) 32.2 (29.3–35.3) 20.6 (17.0–27.7) <0.0001
Cervico–isthmic length, median (IQR) 40.7 (33.9–47.7) 27.0 (17.0–33.8) <0.0001
IQR, interquartile range.
Comparisons between the outcome groups were by Mann–Whitney U -test.

shortening of the isthmus resulting in a decrease in the

median length of the cervico–isthmic complex.
Previous studies investigating the potential value of
first-trimester cervical length in the prediction of preterm
delivery did not distinguish between the endocervix and
isthmus and reported that the mean or median cervical
length was 40 to 44 mm (Zorzoli et al., 1994; Hasegawa
et al., 1996; Carvalho et al., 2003; Conoscenti et al.,
2003; Ozdemir et al., 2007). It is therefore likely that
in these studies the measurement was not confined to
the endocervix but included the whole cervico–isthmic
complex.
The endocervical length was below the median in
all 16 cases with spontaneous early delivery. The
endocervical length was below 25 mm in 6 (37.5%)
of the early preterm delivery group and 42 (2.8%) of
the unaffected pregnancies. The respective values for
endocervical length 25 to 29.9 mm and ≥30 mm were
9 (56.3%) versus 367 (24.6%) and 1 (6.3%) versus
1083 (72.6%). Therefore, the rate of spontaneous early
delivery decreased with endocervical length from 12.5%
Figure 4—Relationship of endocervical length at 11 to 13 weeks
(6 of 48) for length below 25 mm to 2.4% (9 of 376)
with 20 to 24 weeks in women with subsequent spontaneous delivery for length of 25 to 29.9 mm and 0.1% (1 of 1084) for
before 34 weeks (closed circles) and those delivering at or after length of ≥30 mm (χ 2 -test, p < 0.0001).
34 weeks (open circles) At 11 to 13 weeks, the endocervical length in preg-
nancies complicated by subsequent spontaneous delivery
before 34 weeks was shorter than in those deliver-
unfolding, thinning and ‘taking up’ into the body of the
ing after 34 weeks and the risk of early delivery was
uterus but this process leading to the formation of the
inversely related to cervical length. This apparent con-
lower uterine segment is completed only during labour
tradiction between our results and those of previous
(Wendell-Smith, 1954). Ultrasound studies in the 1990s
investigating changes in cervical length throughout ges- first-trimester studies may be explained by the possi-
tation reported that the median or mean length in the bility that in the previous studies the cervico–isthmic
first trimester was 42 to 52 mm and this remained sta- complex rather than the endocervix was measured (Zor-
ble throughout the second trimester with shortening only zoli et al., 1994; Hasegawa et al., 1996; Carvalho et al.,
after 30 weeks (Zorzoli et al., 1994; Tongsong et al., 2003; Conoscenti et al., 2003; Ozdemir et al., 2007). We
1997; Ayers et al., 1998). It is likely that in these stud- also found no significant differences in the length of
ies the cervico–isthmic complex rather than the cervix the cervico–isthmic complex between the two outcome
was measured and the reported shortening in the third groups.
trimester was the consequence of formation of the lower Larger studies involving several thousands of preg-
segment with eventual obliteration of the isthmus. nancies will define the exact relation between cervical
At 11 to 13 weeks, the median length of the endo- length at 11 to 13 weeks and spontaneous early deliv-
cervix and of the cervico–isthmic complex was 32 and ery and the performance of such early screening either
45 mm, respectively. The median endocervical length at by cervical length alone or in combination with maternal
20 to 24 weeks was the same as at 11 to 13 weeks, and characteristics and serum biomarkers (Beta et al., 2010).
there was a significant association in the measurements Similarly, the extent to which early identification of the
between the first and the second trimesters. In contrast, group at high risk of subsequent early delivery would
between 11 to 13 weeks and 20 to 24 weeks there was improve pregnancy outcome through earlier intervention

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2011; 31: 84–89.
DOI: 10.1002/pd
 CERVICAL LENGTH AND PRETERM DELIVERY 89

with such measures as prophylactic use of progesterone Danforth DN. 1947. The fibrous nature of the human cervix, and its relation to
the isthmic segment in gravid and nongravid uteri. Am J Obstet Gynecol 53:
or cervical cerclage remains to be determined. 541–560.
Fonseca RB, Celik E, Parra M, Singh M, Nicolaides KH. 2007. Progesterone
and the risk of preterm birth among women with a short cervix. N Engl J
ACKNOWLEDGEMENT
Med 357: 462–469.
Hasegawa I, Tanaka K, Takahashi K, et al. 1996. A prospective longitudinal
This study was supported by a grant from the Fetal study for the prediction of preterm delivery in a low-risk population. J Matern
Fetal Invest 6: 148–151.
Medicine Foundation (Charity No: 1037116). Heath VC, Southall TR, Souka AP, Elisseou A, Nicolaides KH. 1998. Cervical
length at 23 weeks of gestation: prediction of spontaneous preterm delivery.
Ultrasound Obstet Gynecol 12: 312–317.
REFERENCES Iams JD, Goldenberg RL, Meis PJ, et al. 1996. The length of the cervix and
the risk of spontaneous premature delivery. National Institute of Child Health
and Human Development Maternal Fetal Medicine Unit Network. N Engl J
Althuisius SM, Dekker GA, van Geijn HP, Bekedam DJ, Hummel P. 2000. Med 334: 567–572.
Cervical incompetence prevention randomized cerclage trial (CIPRACT): Kagan K, To M, Tsoi E, Nicolaides K. 2006. Preterm birth: the value of
study design and preliminary results. Am J Obstet Gynecol 183: sonographic measurement of cervical length. BJOG 113: 52–56.
823–829. McCormick MC. 1985. The contribution of low birth weight to infant mortality
Ayers JW, DeGrood RM, Compton AA, Barclay M, Ansbacher R. 1998. and childhood morbidity. N Engl J Med 312: 82–90.
Sonographic evaluation of cervical length in pregnancy: diagnosis and Ozdemir I, Demirci F, Yucel O, Erkorkmaz U. 2007. Ultrasonographic cervical
management of preterm cervical effacement in patients at risk for premature length measurement at 10–14 and 20–24 weeks gestation and the risk of
delivery. Obstet Gynecol 71: 934–944. preterm delivery. Eur J Obstet Gynecol Reprod Biol 130: 176–179.
Berghella V, Talucci M, Desai A. 2003. Does transvaginal sonographic Robinson HP, Fleming JE. 1975. A critical evaluation of sonar “crown-rump
measurement of cervical length before 14 weeks predict preterm delivery length” measurements. BJOG 82: 702–710.
in high-risk pregnancies?. Ultrasound Obstet Gynecol 21: 140–144. Sonek J, Shellhaas C. 1998. Cervical sonography: a review. Ultrasound Obstet
Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. 2005. Cerclage for Gynecol 11: 71–78.
short cervix on ultrasonography: meta-analysis of trials using individual Snijders RJ, Noble P, Sebire N, Souka A, Nicolaides KH; Fetal Medicine
patient-level data. Obstet Gynecol 106: 181–189. Foundation First Trimester Screening Group. 1998. UK multicentre project
Beta J, Akolekar R, Ventura W, Syngelaki A, Nicolaides KH. 2010. Prediction on assessment of risk of trisomy 21 by maternal age and fetal nuchal-
of spontaneous preterm delivery from maternal factors and placental perfusion translucency thickness at 10–14 weeks of gestation. Lancet 352: 343–346.
and function at 11–13 weeks. Pren Diagn xx: xx–xx. To MS, Alfirevic Z, Heath VC, et al. 2004. Cervical cerclage for prevention of
Carvalho MH, Bittar RE, Brizot ML, Maganha PP, Borges da Fonseca ES, preterm delivery in women with short cervix: randomised controlled trial.
Zugaib M. 2003. Cervical length at 11–14 weeks’ and 22–24 weeks’ Lancet 363: 1849–1853.
gestation evaluated by transvaginal sonography, and gestational age at To MS, Skentou CA, Royston P, Yu CK, Nicolaides KH. 2006. Prediction of
delivery. Ultrasound Obstet Gynecol 21: 135–139. patient-specific risk of early preterm delivery using maternal history and
Celik E, To M, Gajewska K, Smith GC, Nicolaides KH; Fetal Medicine sonographic measurement of cervical length: a population-based prospective
Foundation Second Trimester Screening Group. 2008. Cervical length study. Ultrasound Obstet Gynecol 27: 362–367.
and obstetric history predict spontaneous preterm birth: development and Tongsong T, Kamprapanth P, Pitaksakorn J. 1997. Cervical length in normal
validation of a model to provide individualized risk assessment. Ultrasound pregnancy as measured by transvaginal sonography. Int J Gynecol Obstet 58:
Obstet Gynecol 31: 549–554. 313–315.
Centre for Maternal and Child Enquiries (CMACE). 2010. Perinatal Mortality Wendell-Smith CP. 1954. The lower uterine segment. BJOG 61: 87–93.
2008: United Kingdom. CMACE: London. Zorzoli A, Soliani A, Perra M, Caravelli E, Galimberti A, Nicolini U. 1994.
Conoscenti G, Meir YJ, D’Ottavio G, et al. 2003. Does cervical length at Cervical changes throughout pregnancy as assessed by transvaginal
13–15 weeks’ gestation predict preterm delivery in an unselected population? sonography. Obstet Gynecol 84: 960–964.
Ultrasound Obstet Gynecol 21: 128–134.

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2011; 31: 84–89.
DOI: 10.1002/pd