Innovations in Spontaneous Preterm Birth and Cervix

Spontaneous preterm birth (sPTB) is the main cause of neonatal deaths in the world. sPTB is poorly understood and multifactorial, involving main features such as infection/inflammation, bleeding, genetics, poor nutrition, social status, stress, ethnicity/race, and others.

The stages of sPTB dovetail into final unifying processes such as cervical remodeling. To finding that heterogeneous origins result in common downstream biological pathways and outcomes to provides the opportunity to develop rational treatment strategies that target the upstream initiators. In other words, if  identify cervical micro-structural changes prior to preterm birth, it would promote study and understanding of specific molecular events, which would in turn allow conceiving of novel approach to prediction, treatment and ultimately prevention of sPTB through identification of both imaging and molecular bio-markers.

The inverse relationship between a short cervix and preterm birth risk is establishing, and vaginal progesterone supplementation has emerges as a viable treatment. However, this treatment is imperfect; the risk reduction is modest (less than 50%) and the mechanism is unclear, making it difficult to choose the best candidates for the treatment. This is because most women with a short cervix in the mid trimester but no prior history of sPTB deliver at term without treatment, and most preterm births in low risk women occur in those with a normal mid trimester cervical length.

The immensely complex cervix is an investigator challenge. It has layers of collagen that remodel differently, likely because of independent molecular processes, and cause softening and shortening. Extensive micro-structural change has already occurred by the time shortening is evident; this means that cervical softening, which begins soon after conception and continues progressively throughout pregnancy, is likely more critical than shortening.

Many technologies are emerging to assess objectively the softness and microstructure of the pregnant cervix. In order to understand them, it is important to emphasize the central relationship between cervical softness and the organization and composition of the cervical extracellular matrix (ECM) because the pathogenesis of cervical softening and shortening likely relates to dysfunctional remodeling of the ECM. Approaches to evaluating ECM microstructure and softening of the pregnant cervix include elastography, acoustic attenuation, light-induced fluorescence, Raman spectroscopy, cervical consistency index, aspiration, quantitative ultrasound and shear wave speed estimation, among others. These are too numerous to cover in this, so the researchers focus on a few ultrasound-based techniques that have seen recent attention in the literature.

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