title: Anterior uterocervical angle measurement improves prediction of cerclage failure.
abstract: To compare the anterior uterocervical angle and cervical length as predictors of spontaneous preterm delivery in patients with transvaginal cerclage.
  
  
  
  We retrospectively evaluated a cohort of 142 pregnant women with transvaginal cerclage placed over a 5-year period (2010 to 2015) were evaluated. Cervical morphology characteristics were measured from endovaginal imaging, including cervical length, cerclage height, funnel volume and anterior uterocervical angle prior to cerclage placement (UCA 1), shortly after cerclage placement (UCA 2) and the last image prior to delivery (UCA 3). Cerclage failure was defined as delivery prior to 36 weeks. Univariate analysis, receiver operator characteristic curves and binary logistic regression were used for statistical analysis. Statistical significance was defined as a P<0.05.
  
  
  
  Among the 142 women with a transvaginal cerclage, 38% had cerclage failure. The mean gestational age at birth was 29.3±5.2 weeks in the failure group compared with 37.9±2.8 weeks in those that did not fail (P<0.001). Univariate analysis identified cervical length (P=0.034) and UCA 3 (P<0.001) as significantly associated with gestational age at birth. Receiver operator characteristic curves demonstrated improved prediction of delivery prior to 34 weeks at UCA 3=108o(97% sensitivity, 65% specificity) compared to a cervical length of 25 mm. At <28 weeks, optimal performance of UCA 3 was found at 112o(100% sensitivity, 62% specificity) compared with cervical length of 25 mm (29% sensitivity, 39% specificity). Binary logistic regression revealed UCA 3>108oconferred an OR 35.1 (95% CI 7.7 to 160.3) for delivery prior to 34 weeks, and UCA 3>112oan OR 42.0 (95% CI 5.3 to 332.1) for delivery prior to 28 weeks. In comparison, CL<25 mm had an OR 4.7 (95% CI 1.8 to 12.2) for delivery prior to 34 weeks and OR 6.0 (95% CI 1.9 to 19.3) prior to 28 weeks.
  
  
  
  In patients with transvaginal cerclage, an increasingly obtuse anterior uterocervical angle reflects an increased risk of cerclage failure in the mid-trimester. Utilization of UCA measurement as a surveillance tool may improve identification of patients at risk for cerclage failure.
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Knight
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: E
authors.initials: E
authors.lastname: Tenbrink
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: J
authors.initials: J
authors.lastname: Sheng
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA.|Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: A S
authors.initials: AS
authors.lastname: Patil
mesh_terms: D000328:Adult; D023802:Cerclage, Cervical; D002584:Cervix Uteri / Q000000981:diagnostic imaging* / Q000601:surgery*; D005260:Female; D005865:Gestational Age; D006801:Humans; D007196:Indiana; D016015:Logistic Models; D007752:Obstetric Labor, Premature / Q000453:epidemiology* / Q000517:prevention & control; D011247:Pregnancy; D011256:Pregnancy Outcome; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D013536:Suture Techniques; D062606:Tertiary Care Centers; D017211:Treatment Failure; D014463:Ultrasonography; D014621:Vagina; D055815:Young Adult