Original Research
Universal Cervical Length Screening and
Antenatal Corticosteroid Timing
Nicole Sahasrabudhe, MD, Catherine Igel, MD, Ghislaine C. Echevarria, MD, MS, Peer Dar,
Diana Wolfe, MD, Peter S. Bernstein, MD, MPH, Robert Angert, MD, Ashlesha Dayal, MD,
Patience Gallagher, BS, and Mara Rosner, MD
OBJECTIVE: To evaluate the relationship between
universal transvaginal screening for short cervical
length in the second trimester and the timing of
antenatal corticosteroids.
METHODS: We performed a retrospective cohort study
of patients with nonanomalous singleton gestations and
spontaneous preterm birth between 24 and 34 weeks of
gestation after the initiation of a universal transvaginal
cervical length screening program between October
2012 and August 2015. Our primary outcome was
antenatal corticosteroid administration to a delivery
interval of fewer than 7 days. Secondary outcomes
were delivery 24 hours to 7 days after the initial
steroid injection, steroid administration to delivery
interval, neonatal survival, neonatal intensive care
unit length of stay, and respiratory distress syndrome.
Multivariable logistic regression was used to estimate
the association between antenatal corticosteroid tim-
ing and the diagnosis of a short cervix adjusted for
potential confounders.
RESULTS: Among 266 eligible patients, 69 with a short
cervical length and 197 without a short cervical length
were identified. There were no statistically significant
differences in baseline characteristics between the
From the Departments of Obstetrics & Gynecology and Womens Health and
Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center,
Bronx, and the Departments of Anesthesiology, Perioperative Care and Pain
Medicine and Obstetrics and Gynecology, New York University School of Med-
icine, New York, New York.
Presented at the 36th Annual Meeting of the Society for Maternal and Fetal
Medicine, February 6, 2016, Atlanta, Georgia.
Each author has indicated that he or she has met the journals requirements for
authorship.
Corresponding author: Mara Rosner, MD, 150 East 32nd Street, Suite 101,
New York, NY 10016; email: marar01@gmail.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2017 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/17
1104 VOL. 129, NO. 6, JUNE 2017
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD,
groups. During the study period, 64 of 69 (92.8%) of
patients with a short cervix and 176 of 197 (89.3%)
without a short cervix received at least one steroid
injection before delivery (P5.411). Steroids were given
within 7 days of delivery in 33 of 69 (47.8) patients with
a short cervix compared with 126 of 197 (64%) patients in
the no short cervix group (P5.015; adjusted odds ratio
0.51, 95% confidence interval 0.290.9). Median interval
between steroid administration and delivery was 8 days
in patients diagnosed with a short cervix compared with
3 days for those without a short cervical length (P,.001).
CONCLUSION: Patients identified as having a short
cervical length by universal transvaginal ultrasound
screening were at greater risk of delivering more than 7
days after the initiation of corticosteroids for fetal lung
maturation compared with women without a short
cervical length.
(Obstet Gynecol 2017;129:11048)
DOI: 10.1097/AOG.0000000000002029
P reterm birth remains a leading cause of perinatal
morbidity and mortality.1
Fortunately, the rate of preterm birth in the
United States has dropped for the sixth consecutive
year to a 15-year low of 11.5% in 2013.2 This achieve-
ment may be at least partially attributable to the iden-
tification of at-risk patients using second-trimester
ultrasound evaluation of the cervix along with the
use of interventions to prevent preterm birth such as
vaginal progesterone and in patients with a history of
prior preterm birth or cerclage.3,4 For these reasons,
many institutions have adopted a universal transvagi-
nal cervical length screening protocol (Khalifeh A,
Quist-Nelson J, Berghella V. Current implementation
of universal cervical length screening for preterm
birth prevention in the United States [19] [abstract].
Obstet Gynecol 2016;127(suppl 1):7S).
Although antenatal corticosteroids are not an
intervention to reduce preterm birth, the administration
OBSTETRICS & GYNECOLOGY

Fig. 1. Flow diagram.
Sahasrabudhe. Short Cervix and Antenatal Corticosteroid. Obstet
Gynecol 2017.
of antenatal corticosteroids before preterm birth signif-
icantly reduces associated neonatal morbidity and
mortality.5 Timing of corticosteroids appears to be a crit-
ical factor in their efficacy. Although reduction of neo-
natal death is seen at less than 24 hours after a first dose,
studies have failed to show demonstrable mortality or
morbidity benefits at more than 7 days from the first
dose.6 We hypothesized that health care provider con-
cern for impending preterm labor in patients with an
incidental finding of a short cervix might influence
hasty steroid dosing, potentially putting these patients
at risk for suboptimal antenatal corticosteroid timing.
The aim of this study was to assess the relationship
between patients identified as having a short cervix as
Fig. 2. Linear regression modeling the relationship
between cervical length at the time of second-trimester
transvaginal ultrasonography and antenatal corticosteroid
administration to delivery interval. For every 10-mm
decrease in cervical length, the predicted increase in
antenatal corticosteroid administration to delivery interval
was 1.5 days. Gray area indicates 95% confidence interval.
Black line indicates fitted values.
Sahasrabudhe. Short Cervix and Antenatal Corticosteroid. Obstet
Gynecol 2017.
VOL. 129, NO. 6, JUNE 2017 Sahasrabudhe et al
Copyright by The American College of Obstetricians
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part of a universal transvaginal cervical length screening
protocol and the timing of administration of antenatal
corticosteroids in relation to the timing of birth.
MATERIALS AND METHODS
Our institution adopted a universal transvaginal
cervical length screening protocol in October 2012
for all women with a singleton gestation undergoing
a routine anatomy ultrasonogram between 17 0/7
weeks and 23 6/7 weeks of gestation. After obtaining
Montefiore Medical Center institutional review board
approval, we retrospectively analyzed the electronic
records of all women who experienced spontaneous
preterm delivery between 24 0/7 weeks and 34 0/7
weeks of gestation after the initiation of universal
transvaginal cervical length screening (October 2012)
at our institution until August 2015.
Patients with major fetal anomalies, multiple
gestations, iatrogenic preterm deliveries resulting
from maternal or fetal indications, and patients who
did not deliver at our institution were excluded.
Maternal demographics and medical and obstetric
history data were obtained through electronic medical
records. Gestational age and cervical length at the initial
transvaginal ultrasonogram and on any follow-up ultra-
sonograms were recorded. Short cervix was defined as
2.0 cm or less in the absence of prior spontaneous
preterm birth or less than 2.5 cm if there was a history
of prior spontaneous preterm birth.7 Neonatal data
including gestational age at delivery, birth weight, gen-
der, admission to the neonatal intensive care unit, respi-
ratory distress syndrome (RDS), and neonatal demise
were also recorded. Each maternal and neonatal record
was individually reviewed by study investigators.
All episodes of antenatal corticosteroid dose
administration were identified. We considered one
dose to be an incomplete initial steroid course, two
doses a completed course, three doses an incomplete
rescue course, and four doses as a complete rescue
course. The interval of days to delivery from antenatal
corticosteroid administration was recorded. In the
event a patient received a rescue antenatal corticoste-
roid course, timing from antenatal corticosteroid
administration to delivery was based on the patients
most recent (ie, rescue) antenatal corticosteroid
course. Optimal steroid timing was considered a ste-
roid to delivery interval of 24 hours to 7 days (allow-
ing for a complete steroid course).
The primary outcome was delivery within 7 days
of the first dose (initial or rescue) of antenatal
corticosteroid. Secondary outcomes included delivery
24 hours to 7 days after the initial steroid injection,
antenatal corticosteroid to delivery interval in days,
Short Cervix and Antenatal Corticosteroids 1105
Table 1. Baseline Characteristics

Characteristic Short Cervical Length (n569) No Short Cervical Length (n5197) P

Maternal age (y) 29.860.7 28.960.5 .353

Race
Hispanic 30 (43.5) 66 (33.5) .147
Black 17 (24.6) 52 (26.4) .874
Caucasian 4 (5.8) 9 (4.6) .747
Asian 4 (5.8) 8 (4.1) .515
Unknown or other 14 (20.3) 62 (31.5) .089
Nulliparous 29 (42.0) 85 (43.2) .872
History of full-term delivery 28 (40.6) 81 (41.1) .938
History of preterm delivery 24 (34.8) 57 (28.9) .300
Cervical length at anatomy (cm) 1.5 (0.81.9) 3.9 (3.34.5) ,.001
Gestational age at delivery (wk) 28.3 (26.132.3) 31.3 (28.032.9) .006
Insurance (public or private) 52/17 153/44 .695
Diabetes mellitus (including GDM) 14 (20.3) 29 (14.7) .280
GDM, gestational diabetes mellitus.
Data are mean6standard deviation, n (%), or median (interquartile range) unless otherwise specified.

the incidence of delivery after a complete steroid elimination approach, the likelihood ratio test com-
course, neonatal survival, neonatal intensive care unit paring the model including the variable with the
length of stay, and RDS. nested model excluding it was used to assess whether
We tested normality using the Shapiro-Wilk test the variable contributed significantly to the model
and Q-Q plots. We used unpaired Student t test or (P,.20). The HosmerLemeshow goodness-of-fit test
Wilcoxon rank-sum test for between-group compari- was used to assess calibration of the model.
sons, as appropriate. x2 test and Fisher exact test were Among patients with known short cervix, the
used for inferences on proportions. potential association of cerclage and the use of vaginal
A multivariable logistic regression model was progesterone on the timing of antenatal corticosteroid
used to quantify the association between optimal administration was also studied. Data are expressed as
timing of antenatal corticosteroids and a short cervix. mean (standard deviation), median (interquartile
The model building was done according to Hosmer range), or odds ratio (95% confidence interval), unless
and Lemeshow.8 Variables identified as potential con- otherwise stated. A two-sided P value ,.05 was con-
founding factors and those with a P value of ,.25 in sidered significant. All analyses were performed with
the univariable analysis were included in the multivar- STATA/SE 12.1.
iable logistic regression model. Using a backward
RESULTS
Table 2. Univariable Analysis: Odds Ratio of A total of 1,253 patients had spontaneous preterm
Receiving Antenatal Corticosteroids birth before 34 weeks of gestation within the study
Within 7 Days of Delivery (N5266)
Table 3. Multivariable Logistic Regression Analysis:
Variable OR (95% CI) P Odds Ratio of Receiving Antenatal
Corticosteroids Within 7 Days of Delivery
Age (1-y increment) 0.98 (0.941.02) .283
Gestational age (1-d increment) 1.00 (0.991.01) .637 Unadjusted Adjusted
History of preterm birth 0.56 (0.330.96) .035 Variable OR (95% CI) OR (95% CI) P
Private insurance* 1.22 (0.682.22) .500
Race Short cervical 0.50 (0.290.88) .015
Hispanic 1 length*
Black 1.04 (0.551.95) .907 Short cervical 0.51 (0.290.90) .019
Caucasian 1.60 (0.465.55) .463 length*
Asian 2.13 (0.548.37) .280 History of 0.58 (0.340.99) .045
Unknown or other 1.03 (0.561.90) .927 preterm birth
Diabetes mellitus (including GDM) 0.92 (0.671.25) .587
OR, odds ratio; CI, confidence interval.
OR, odds ratio; CI, confidence interval; GDM, gestational diabetes Hosmer and Lemeshows goodness-of-fit test for the adjusted
mellitus. model, P5.13.
* Reference group is public insurance. * Reference group is no short cervical length.

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Table 4. Antenatal Corticosteroid Administration and Neonatal Outcomes

Short Cervical No Short Cervical

Outcome Length (n569) Length (n5197) P

Antenatal corticosteroid-to-delivery interval 7 d or less 33 (47.8) 126 (64.0) .015

Antenatal corticosteroid-to-delivery interval (d) 8 (219) 3 (19) ,.001
Any antenatal corticosteroid dose before delivery 64 (92.8) 176 (89.3) .411
Complete course of steroid 62 (89.9) 158 (80.2) .068
Optimal interval 24 h to 7-d interval or less 30 (43.5) 87 (44.2) .922
NICU stay (d) 47 (2095) 34 (1666) .011
Neonatal RDS 53 (76.8) 150 (76.1) .910
Neonatal mortality 4 (5.8) 8 (4.1) .550
NICU, neonatal intensive care unit; RDS, neonatal respiratory distress syndrome.
Data are n (%) or median (interquartile range) unless otherwise specified.
Optimal timing antenatal corticosteroid when given within the optimal 7-day window before delivery.

period, October 2012 to August 2015. Of those, 987
were excluded from the analysis for multiple gesta-
tion, fetal anomalies, iatrogenic preterm birth result-
ing from secondary causes such as preeclampsia and
growth restriction, or missing data. Of the remaining
266 patients, 69 (25.9%) had a short cervix at the time
of their universal transvaginal cervical length screen
and 197 (74.1%) did not (Fig. 1).
Patients in the short cervical length group had
a median cervical length of 1.5 (0.81.9) cm at the time
of the second-trimester transvaginal ultrasonography
(Fig. 2) compared with 3.9 (3.34.5) cm in the no short
cervical length group (P,.001) and were more likely to
deliver at an earlier gestational age (P5.006; Table 1).
During the study period, 64 of 69 (92.8%) of
patients with a short cervix and 176 of 197 (89.3%)
without a short cervix received at least one steroid
injection before delivery (P5.411). At least one dose of
steroids was given within 7 days of delivery in 33 of 69
(47.8) patients with a short cervix compared with 126 of
197 (64%) patients in the no short cervix group
(P5.015). When the optimal interval of 24 hours to 7
days was considered, there was no difference between
groups (30/69 [43.5%] of those with a short cervix com-
pared with 87/197 [44.2%] of those without; P5.922).
The results of the univariable and multivariable
logistic regression analysis are shown in Tables 2 and 3,
respectively. The adjusted odds ratio of receiving ante-
natal corticosteroid within 7 day before delivery was
0.51 (95% confidence interval 0.290.9) when compar-
ing the short cervical length group with the no short
cervical length group. The median interval between the
antenatal corticosteroid administration and delivery
was significantly shorter in the no short cervical length
group compared with the short cervical length group (3
days compared with 8 days, P,.001; Table 4).
The median injection to delivery interval for
patients who delivered less than 7 days but before
receiving a complete steroid course was 6.9 (1.19.9)
hours. For the seven patients in the short cervical
length group, the median dose to delivery interval
was 11.5 (1.618.1) hours and for those in the no short
cervical length group (n539), the median dose to
delivery interval was 5.7 (1.19.6) hours (P5.293).
Within the short cervical length group, a cerclage
procedure was performed in 23 (33.3%) patients and
vaginal progesterone was used by 29 (42%). In the
subgroup analyses, no differences were seen in the
optimal timing of antenatal corticosteroid administra-
tion and the presence of cerclage or use of vaginal
progesterone (P5.610 and P5.164, respectively).
Although neonates from women with short cer-
vical length had a longer neonatal intensive care unit
stay compared with women without a short cervical
length (47 compared with 34 days; P5.011), this dif-
ference was not significant after controlling for gesta-
tional age at delivery (P5.149). Similarly, there was
no difference in neonatal survival or RDS between the
groups (Table 4).
DISCUSSION
In this study, we found that patients identified with
a short cervix on universal transvaginal cervical
length screening and who subsequently delivered
prematurely had a significantly longer interval from
antenatal corticosteroid administration (8 days com-
pared with 3 days) and fewer of them received
antenatal corticosteroid within 7 days of birth com-
pared with patients with spontaneous preterm birth
who were not identified as having a short cervix by
universal transvaginal cervical length screening. How-
ever, a similar percentage of patients in both groups
delivered within the optimal interval of 24 hours to 7
days. Neonatal outcomes were similar between these
two groups; however, our study was not powered to
assess differences in neonatal outcomes.

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 This study highlights the clinical dilemma for
physicians caring for patients with an incidentally
identified short cervix trying to balance the risk of
administering corticosteroids too early with the risk of
administering them too late. Although available data
suggest that a timely yet incomplete course of
antenatal corticosteroids may confer greater benefit
over a remote yet completed course,6 robust data are
lacking. This dilemma extends to rescue steroids:
Makhija et al9 showed that the option of giving a res-
cue course did not translate into an increased number
of patients receiving optimally timed steroids.
Our results are in contrast to the findings of Adams
et al10 who identified a cervical length less than 2 cm as
a factor that was associated with optimal timing of
antenatal corticosteroids. Our findings do, however,
align with the results of Makhija et al.9 They noted that
patients with a short cervical length had the lowest rates
of optimally timed steroids among their entire cohort
(only 2.8% compared with an average of 25% for other
groups delivered within the optimal window).
The significance of suboptimally timed steroids is
yet to be fully clarified. In 1972, groundbreaking work
by Liggins et al5 compared unexposed patients with
those who had received antenatal corticosteroid less
than 24 hours, 2448 hours, 27 days, and then at
greater than 7 days exposure to delivery intervals
and found a significant improvement in the rate of
RDS only in the 2- to 7-day group. Subsequent studies
comparing neonates who received antenatal cortico-
steroid with optimal compared with suboptimal tim-
ing have been conflicting.1114 In a meta-analysis,
Crowley found that neonates who were delivered after
optimally timed steroids had an odds ratio of 0.35 for
RDS, whereas those who were delivered less than 24
hours or greater than 7 days after receiving steriods
did not demonstrate a statistically significant reduc-
tion in RDS.15 Unfortunately, all of these studies have
all been limited by sample size and have focused pri-
marily on the prevention of RDS.
Our study was not without limitations. We had
outcome data only for women who delivered in our
institution, and they comprised the minority of
women who underwent universal transvaginal cervi-
cal length screening. Our relatively small sample size
limited our statistical power to detect differences in
neonatal outcomes. Management decisions made
about corticosteroid administration were not stan-
dardized. We did not include patients with a short
cervix who went on to deliver after 34 weeks of
gestation. Including those patients would have likely
contributed to a longer steroid to delivery interval for
patients in the short cervix group.
1108 Sahasrabudhe et al Short Cervix and Antenatal Corticosteroids
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
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In summary, a policy of universal transvaginal
cervical length screening may increase the likelihood
that corticosteroids for fetal maturation are adminis-
tered less than optimally.
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