Systematic Review

Ultrasonographic cervical length assessment

in pregnancies with placenta previa and risk
of perinatal adverse outcomes: a systematic
review and meta-analysis
Kamran Hessami, MD; Matthew Mitts, DO; Nikan Zargarzadeh, MD; Marzieh Jamali, MD; Vincenzo Berghella, MD;
Alireza A. Shamshirsaz, MD

Introduction

P lacenta previa is associated with sig-

nificant maternal and neonatal
morbidity and mortality, primarily ante-
OBJECTIVE: This study aimed to examine the association between cervical length and the risk
of adverse outcomes in placenta previa pregnancies. In addition, the diagnostic accuracy of
cervical length in predicting emergency cesarean delivery due to hemorrhage was evaluated.
partum hemorrhage (APH) and preterm DATA SOURCES: PubMed, Web of Science, and Embase were systematically searched up to
birth (PTB), respectively, with 52% of January 21, 2023.
pregnancies affected by placenta previa STUDY ELIGIBILITY CRITERIA: Observational studies investigating the relationship between
resulting in APH and 44% with PTB.1,2 cervical length and maternal adverse outcomes in patients with placenta previa were consid-
Placenta previa affects approximately 4 ered eligible. The primary outcome was the diagnostic accuracy of cervical length measured
at 28 to 34 weeks of gestation for the prediction of emergency cesarean delivery due to hem-
Cite this article as: Hessami K, Mitts M, Zargarzadeh N,
orrhage. The secondary outcomes were the probability of antenatal bleeding, preterm birth
et al. Ultrasonographic cervical length assessment in (both iatrogenic and spontaneous), and postpartum hemorrhage >2000 mL. Insufficient data
pregnancies with placenta previa and risk of perinatal were available on the transfusion procedure in cases where the cervical length was <30 mm.
adverse outcomes: a systematic review and meta-analy- METHODS: For prognostic analysis, the random-effects model was used to pool the odds
sis. Am J Obstet Gynecol MFM 2024;6:101172. ratios and the corresponding 95% confidence intervals. For the diagnostic part, we used a
From the Maternal Fetal Care Center, Boston
summary receiver-operating characteristic curve, pooled sensitivities and specificities, area
Children’s Hospital, Harvard Medical School, under the curve, and summary likelihood ratios.
Boston, MA (Drs Hessami, Zargarzadeh, RESULTS: A total of 13 studies presenting data on 1462 pregnancies with placenta previa
Jamali, and Shamshirsaz); Department of were included. Cervical length ≤30 mm at 28 to 34 weeks of gestation had a sensitivity of
Obstetrics and Gynecology, Baylor College of 61% (95% confidence interval, 43−77), specificity of 83% (95% confidence interval,
Medicine, Houston, TX (Dr Mitts); Division of
Maternal-Fetal Medicine, Department of
76−88), and area under the curve of 0.83 (95% confidence interval, 0.80−0.86) for the pre-
Obstetrics & Gynecology, Sidney Kimmel diction of emergency cesarean delivery. Furthermore, cervical length ≤30 mm was associated
Medical College, Thomas Jefferson University, with antenatal bleeding (odds ratio, 3.62; 95% confidence interval, 2.09−6.26; P<.001;
Philadelphia, PA (Dr Berghella); Gene Therapy I2=54.8%), preterm birth (odds ratio, 8.46; 95% confidence interval, 3.05−23.44; P<.001;
Research Center, Digestive Diseases Research I2=83.6%), and postpartum hemorrhage (odds ratio, 6.89; 95% confidence interval,
Institute, Tehran University of Medical Sciences,
Tehran, Iran (Dr Jamali).
4.51−10.53; P<.001; I2=0.00%).
CONCLUSION: Short cervical length (≤30 mm) measured at 28 to 34 weeks of gestation can
Received June 1, 2023; revised September 21,
2023; accepted September 26, 2023. assist in predicting the risk of emergency cesarean delivery due to hemorrhage in pregnancies
The authors report no conflict of interest.
with placenta previa. Furthermore, short cervical length is significantly associated with the risk
of antenatal bleeding, preterm birth, and postpartum hemorrhage in pregnancies with placenta
The authors report no funding for this study.
previa.
Data supporting these findings are available
from the corresponding author upon Key words: cesarean, emergency, hemorrhage, placenta previa, ultrasound
reasonable request.
The study protocol for this systematic review
was registered in the PROSPERO international
prospective register of systematic reviews in 1000 deliveries, and because of its digital examination that disrupts the
(registration number: CRD42023393556). association with cesarean delivery (CD), inelastic placental attachment site and
Corresponding author: Alireza A. Shamshirsaz, the rate of placenta previa is increasing leads to bleeding. Accurate prediction of
MD. [email protected]. with the CD rate.3,4 Despite the rise in APH could lead to improved maternal
edu rates of placenta previa, the pathophysi- and neonatal outcomes by decreasing the
2589-9333/$36.00 ology of APH has remained elusive. It is rate of hemorrhage, emergency CD, and
© 2023 Elsevier Inc. All rights reserved. considered to involve shearing forces morbidity related to preterm delivery.
http://dx.doi.org/10.1016/j.
from uterine changes, contractions, or Ultrasound measurements have
ajogmf.2023.101172
outside forces such as coitus or due to been evaluated as possible tools for

May 2024 AJOG MFM 1

Systematic Review

AJOG MFM at a Glance were added to the results from the

electronic literature search. Unpublished
Why was this study conducted? materials and resources were not
This study was undertaken to examine the association between cervical length checked as a part of the literature search.
(CL) and the risk of adverse outcomes in placenta previa pregnancies. In addi-
tion, the diagnostic accuracy of CL in predicting emergency cesarean delivery
(CD) due to hemorrhage was evaluated. Eligibility criteria and study selection
The index test in this meta-analysis was
Key findings ultrasound-measured CL, and the refer-
Short CL (≤30 mm) was significantly associated with higher risk of antenatal ence standard was the incidence of
bleeding, preterm birth, and postpartum hemorrhage. Short CL at 28 to 34 weeks emergency CD due to bleeding.
of gestation had a sensitivity of 61% (95% confidence interval [CI], 43%−77%), Included studies were prospective or
specificity of 83% (95% CI, 76%−88%), and an area under the curve of 0.83 retrospective cohorts with pregnant
(95% CI, 0.80−0.86) for the prediction of emergency CD. individuals with antenatally suspected
What does this add to what is known? placenta previa. The exclusion criteria
Shortened CL has been linked to heightened risk of adverse pregnancy outcomes included reviews; letters, comments,
in pregnancies complicated by placenta previa. These outcomes encompass editorials, or protocol studies; guide-
emergency CD resulting from bleeding, antenatal bleeding, preterm birth, and lines; studies not written in English; and
postpartum hemorrhage. CL measurement shows potential in predicting the risk systematic reviews and meta-analyses.
of emergency CD in placenta previa cases, rendering it a potentially valuable
diagnostic tool for informing clinical decision-making when managing these
Prognostic meta-analysis
high-risk pregnancies.
The primary aim of this meta-analysis
was to evaluate the odds ratio (OR) of
emergency CD occurring according to
predicting adverse outcomes resulting Materials and Methods
the CL in the case of placenta previa.
from placenta previa, including loca- This systematic review and meta-analysis
The secondary aims were to explore the
tion, presence of lacunae, marginal followed the methodological instructions
ORs of: (1) antenatal bleeding, (2) PTB,
sinuses, velamentous cord, and cervical of the JBI manual for systematic reviews.
and (3) postpartum hemorrhage (PPH).
length (CL).5−8 However, the results We reported our findings according to
have overall remained inconclusive. the PRISMA (Preferred Reporting Items
The only clear relationship established for Systematic Reviews and Meta-Analy- Diagnostic analysis
is the predictive value of CL for pre- ses) checklist. The study protocol for this The diagnostic analysis aimed to
term labor, with a CL of 30 mm being systematic review was registered in explore the diagnostic performance
associated with a nearly 4-fold higher PROSPERO (International prospective (pooled sensitivity, specificity, positive/
risk for PTB.9,10 Given that the mecha- register of systematic reviews; registra- negative likelihood ratios [LRs], and
nism for APH in placenta previa is tion number: CRD42023393556). area under the curve [AUC]) of CL
likely related to cervical effacement, it measured at 28 to 34 weeks of gestation
is plausible that an association of cervi- Search strategy in the prediction of emergency CD due
cal shortening and APH exists in A systematic literature search was per- to bleeding.
patients with placenta previa. Numer- formed by 2 independent authors (K.H.
ous studies have previously investi- and N.Z.) on PubMed, Web of Science,
gated this correlation, yielding diverse and Embase from inception to January Data extraction
outcomes—some in agreement11,7 and 21, 2023. The search was conducted For each included article, data on clini-
others in disagreement.12,13 using the following key words: (((cervi* cal and methodological study character-
To the best of our knowledge, no [Title/Abstract]) AND ((sonograph* istics were extracted independently by 2
previous review study assessed the [Title/Abstract]) OR (ultrasound[Title/ reviewers (K.H. and N.Z.) on data-
prognostic and diagnostic characteris- Abstract]))) OR (((cervical length mea- extraction forms. Any disagreements
tics of short CL in pregnancies with surement[MeSH Terms]) OR (Cervical were resolved by consensus and, if nec-
antenatally suspected placenta previa. Length Measurement[Title/Abstract])) essary, by a third author (A.A.S.). The
Thus, this study was undertaken to OR (“Cervical Length Measurement- following data were abstracted: author’s
examine the association between CL s”[Title/Abstract]))) AND (“previa*” name, country, publication year, study
and the risk of adverse outcomes in [Title/Abstract] OR “marginal placen- design, number of participants with
placenta previa pregnancies. In addi- ta”[Title/Abstract] OR “partial placen- antenatal suspected placenta previa,
tion, the diagnostic accuracy of CL in ta”[Title/Abstract]). timing of ultrasound measurement of
predicting emergency CD due to hem- References of relevant articles were CL, cutoff values used in each study,
orrhage was evaluated. manually reviewed, and eligible studies and the method of CL measurement.

2 AJOG MFM May 2024

 Systematic Review

Quality assessment Statistical analysis CIs were calculated from the true-posi-
The Newcastle−Ottawa scale (NOS) All statistical analyses were performed tives, false-positives, false-negatives,
tool was used to evaluate the risk of bias using Stata, version 17.0 (StataCorp LLC, and true-negatives from each study, to
of the included cohort studies by 2 College Station, TX). For the prognostic indicate the accuracy of CL in the pre-
independent reviewers (K.H. and N.Z.). part, pooled summary effect sizes were diction of emergency CD due to bleed-
A score >7 is considered to indicate presented using mean difference or OR ing. In addition, a summary receiver-
high quality. The QUADAS-2 (Quality with 95% confidence interval (CI). operating characteristic curve was con-
Assessment of Diagnostic Accuracy For the diagnostic part, overall structed. The heterogeneity of the
Studies−2) checklist was used for pooled sensitivities, specificities, posi- pooled studies was assessed by the
assessing the risk of bias in the included tive LR (LR+), negative LR (LR-), and inconsistency index (I2). I2 >50% indi-
studies of diagnostic accuracy. diagnostic ORs with corresponding 95% cates significant heterogeneity.

FIGURE 1
PRISMA flowchart for study selection

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Hessami. Cervical length and adverse pregnancy outcome in placenta previa. Am J Obstet Gynecol MFM 2023.

May 2024 AJOG MFM 3

4 AJOG MFM May 2024

Systematic Review
TABLE
Characteristics of the included studies
Sample
Study Design size CL measured at CL cutoff Inclusion Exclusion PTB definition NOS
14
Altraigey et al, Retrospective 328 20−34 wk 30 mm Singleton pregnancies Threatened preterm labor, multiple gestations, 37 wk 8
2021 diagnosed with placenta rupture of the fetal membranes, polyhydramnios,
Saudi Arabia previa before 34 wk of fetal growth restriction, fetal anomalies, history
gestation of cervical operations, presence of cervical
cerclage, use of tocolysis, and medical disorders
that necessitated termination of pregnancy. In
addition, women whose CL measurements
indicated different types of intervention,
according to their gestational ages, were
excluded.
Urmila et al,15 NR 70 28−34 wk 30 mm Women with Antenatal Cause of antepartum hemorrhage other than NR N/A
2013 diagnosed placenta previa placenta previa, gestational age <20.0 and
India >36.0 completed wk, multiple pregnancy,
threatened preterm labor or premature rupture of
membranes, history of cervical cone biopsy,
presence of cerclage, sonographic suspicion of
fetal anomaly or fetal growth restriction, history
of maternal bleeding disorder or hypertensive
disease complicating pregnancy
Fukushima Retrospective 80 24−33 wk 30 mm Diagnosis of placenta previa by Threatened preterm labor at the time of CL 34 wk 7
et al,11 2012 transvaginal sonography measurement, multiple gestations, ruptured
Japan before 34 wk of gestation membranes, evidence of polyhydramnios, fetal
growth restriction, fetal anomalies, or medical
disorders complicating the pregnancy
Stafford et al,16 Prospective 68 At approximately 30 mm All singleton gestations with Multifetal gestation or history of uterine anomalies 34 and 37 N/A
2010 32 wk placenta previa undergoing
United States ultrasound evaluation at the
hospital at ≥24 wk of
gestation
Hasegawa et al,13 Retrospective 182 NR 25 mm Patients with a singleton Cases with low-lying N/A 7
2011 pregnancy and placenta previa placentas
Japan who underwent cesarean
delivery between 2000 and
2009 at the university hospital
Sekiguchi et al,17 Retrospective 71 At least every 2 wk from 25 and 30 mm Singleton pregnancies and Absence of cervical length measurements and 34 wk 7
2015 24−36 wk of gestation placenta previa indications for preterm cesarean delivery other
Japan as part of routine than vaginal hemorrhage
medical
checkups at our
hospitala

(continued)
 TABLE
Characteristics of the included studies (continued)
Sample
Study Design size CL measured at CL cutoff Inclusion Exclusion PTB definition NOS
18
Mimura et al, Retrospective 115 At approximately 32 wk 25 mm Singleton pregnancies with Patients with low-lying placenta N/A 7
2011 of gestation placenta previa
Japan
Mitsuzuka et al,19 Retrospective 129 CL was measured 30 mm Singleton pregnant women with Patients with multiple pregnancies, fetal N/A N/A
2022 biweekly between 20 placenta previa who delivered anomalies, or low-lying placentas
Japan and 35 wk of at the institution from January
gestationb 2010 to December 2016
Shin et al,20 2016 Retrospective 93 All women in the study 25 mm Women who delivered neonates Patients with any of the following: low-lying N/A 6
South Korea were offered serial at the hospital and who were placenta, multifetal gestation, preterm delivery
measurement of CL by diagnosed with placenta without vaginal bleeding, premature rupture of
transvaginal ultrasound previa at delivery membranes, history of conization, presence of
at 19−23 (CL1), 24−28 cerclage, maternal disease, or hypertensive
(CL2), 29−31 (CL3), disorder during pregnancy, and clinical
and 32−34 wk (CL4) chorioamnionitis.
Syed et al,21 2022 Retrospective 75 At third trimester 25 mm Already diagnosed cases of Morbidly adherent placentas, hemodynamic 37 6
Pakistan placenta previa, with singleton instability, coexisting placental abruption, fetal
live pregnancies at ≥28 wk of anomalies, medical comorbidities such as
gestation diabetes, hypertension, and history of preterm
delivery
Ghi et al,12 2009 Prospective 59 27−36 wk 31 mm All asymptomatic women Any of the following conditions: gestational age 34 N/A
Italy diagnosed consecutively with <27.0 and ≥36.0 completed wk; multiple
complete placenta previa at pregnancy; threatened preterm labor or
the ultrasound laboratory of premature rupture of membranes; history of
the university hospital bleeding in the current pregnancy;
polyhydramnios; history of cervical cone biopsy;
presence of cerclage; maternal use of vaginal
progesterone; sonographic suspicion of fetal
anomaly or fetal growth restriction; history of
maternal disease or hypertensive disorder
complicating the pregnancy
Zheng et al,22

Systematic Review
Retrospective 80 NR 30 mm (1) pregnant women diagnosed (1) comorbid psychiatric disorders; (2) multiple NR 7
2021 with placenta previa by births; (3) history of cervical surgery; (4)
China imaging; (2) complete medical comorbid cervical lesions; (5) comorbid
records; (3) single live birth. coagulopathy; (6) fetal malformations; (7)
May 2024 AJOG MFM

comorbid severe organ failure; (8) comorbid

congenital heart disease; and (9) comorbid
underlying diseases such as gestational
hypertension.

(continued)
5
Systematic Review

Results
PTB definition NOS
Search strategy and study selection

6
A total of 471 articles were retrieved. Of
those, 163 articles were excluded for
duplication. The remaining 308 studies
37 wk

were screened for eligibility. Title and

abstract screening resulted in 32 poten-
pregnancy, (2) multiple gestation, (3) previous or

tially eligible studies. After a full-text

current threatened preterm labor, (4) history of

medical disorders complicating the pregnancy

evidence of polyhydramnios, (5) fetal growth

assessment was conducted, 13 studies

cervical cerclage, ruptured membranes, or

restriction or fetal anomalies, (6) history of

met our inclusion criteria and were

(1) present or past bleeding in the current

included in this review (Figure 1).

Study characteristics
The characteristics of the included
studies are shown in the Table. Data
collection was retrospective in 10
studies,7,11,13,14,17−22 prospective in 2
studies,12,16 and study design was not
Exclusion

reported for 1 study.15 Included studies

reported data on 1462 patients with
antenatally suspected placenta previa
was confirmed when the lower
wk as determined by a reliable

who had CL assessment, of whom 597

ultrasound examination before

overlay the internal cervical os

gestational age >28 and <36

period and confirmed by early

complete placenta previa that

date of last normal menstrual

(40.8%) had short CL and 865 (59.2%)

placental edge completely
(1) singleton pregnancy, (2)

had normal CL. Eight studies defined

20 wk of gestation, (3)

short CL as ≤30 mm, and 5 studies as

<25 mm. The quality assessment find-
CL: cervical length; N/A: not applicable; NOS: Newcastle−Ottawa scale; NR: not reported; PTB: preterm birth; TVS: transvaginal sonography.

ings of the included studies using NOS

diagnosis of

The last ultrasound scan used for CL assessment; b The shortest CL measured throughout gestation in each patient was used for analysis.

score are shown in the Table. Studies

Inclusion

on TVS

designed as diagnostic were assessed

with QUADAS-2, and their results are
Hessami. Cervical length and adverse pregnancy outcome in placenta previa. Am J Obstet Gynecol MFM 2023.

summarized in the Supplemental Table.

CL cutoff

Synthesis of results
30 mm

Prognostic characteristics of short cervical

length for risk of adverse pregnancy
outcomes in placenta previa. The proba-
CL measured at

bility of emergency CD due to bleeding

Characteristics of the included studies (continued)

was significantly higher among patients

with placenta previa who had short CL
than among those with normal CL (OR:
NR

8.04; 95% CI: 4.54−14.24; P<.001;

I2=0.0%). Furthermore, compared with
Sample
size

those with normal CL, patients with pla-

Retrospective 54

centa previa who had short CL had sig-

nificantly higher probability of PTB (OR:
5.31; 95% CI: 2.68−10.52; P<.001;
Design

I2=43.2%) (Figure 2). However, the asso-

ciation of short CL with antenatal bleed-
ing was comparable between the 2
7

groups (OR: 3.44; 95% CI: 0.72−16.41;

Zaitoun et al,

P=.121; I2=77.2%). The probability of

TABLE

Egypt
2011

emergency CD was significantly higher

Study

regardless of the short CL definition

a

(either <25 or ≤30 mm) (Figure 3).

6 AJOG MFM May 2024

 Systematic Review

FIGURE 2
Pooled risk of emergency CD, antenatal bleeding, PTB, and PPH

Meta-analysis of the risk of (A) emergency CD, (B) antenatal bleeding, (C) preterm birth, and (D) postpartum hemorrhage
CD: cesarean delivery; CI: confidence interval.
Hessami. Cervical length and adverse pregnancy outcome in placenta previa. Am J Obstet Gynecol MFM 2023.

Diagnostic accuracy of short cervical 43%−77%), specificity of 83% (95% CI: Discussion
length for risk of emergency cesarean 76%−88%), LR+ of 3.5 (95% CI: Main findings
delivery in placenta previa. CL 2.5−5.0), LR- of 0.47 (95% CI: The investigated outcomes were the
measured at 28 to 34 weeks had an 0.31−0.72), and AUC of 0.83 (95% CI: probability of emergency CD, APH,
overall sensitivity of 61% (95% CI: 0.80−0.86) (Figure 4). PTB, and PPH. The current meta-

May 2024 AJOG MFM 7

Systematic Review

FIGURE 2. CONTINUED

analysis demonstrates that third-trimes- reduction of mechanical strength recommend against performing routine
ter measurements of CL in patients with involving dilation and effacement. This transvaginal CL screening for pregnan-
placenta previa are both sensitive and is considered to cause instability at the cies with placenta previa (GRADE 2B).
specific in predicting emergency CD. site of placental attachment, resulting in This recommendation is primarily
The results also showed that short CL is tearing of placental vessels, leading to based on 3 observational studies that
associated with increased risk of adverse massive bleeding.23,24 Consequently, involved a limited number of patients.
pregnancy outcomes, including emer- APH typically occurs in the third tri- The authors of these studies acknowl-
gency CD due to bleeding, antenatal mester when physiological changes of edged that although an association
bleeding, PTB, and PPH. This study the cervix during pregnancy begin to between shortened CL and PTB in the
reinforces the existing evidence that develop.11 presence of placenta previa may exist,
short CL is a significant risk factor for According to the Society for Mater- no prospective studies have tested a
adverse pregnancy outcomes in women nal-Fetal Medicine Consult Series titled management strategy based on CL.
with placenta previa. “The Role of Routine Cervical Length Our meta-analysis also demonstrated
Screening in Selected High- and Low- that CL measurement has moderate
Comparison with existing literature Risk Women for Preterm Birth Preven- sensitivity and specificity in predicting
The mechanism of hemorrhage in tion,”25 it has been observed that there emergency CD in placenta previa. The
patients with placenta previa is not well are insufficient data to support the clini- pooled sensitivity of 64% and specificity
established; however, the cervix is cal benefit of routine CL measurement of 77% suggest that third-trimester CL
known to undergo adaptations during or surveillance in the context of pla- measurement is a reasonably valid diag-
the gestational course that result in a centa previa. As a result, they nostic tool in identifying women who

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 Systematic Review

FIGURE 3
Risk of emergency CD among pregnancies CL <25 and <30 mm

CD: cesarean delivery; CI: confidence interval.

Hessami. Cervical length and adverse pregnancy outcome in placenta previa. Am J Obstet Gynecol MFM 2023.

may require emergency CD due to the likelihood of having an emergency different management in clinical set-
bleeding in the context of placenta pre- CD by nearly 3-fold. Given that the tings.26 However, only 1 study16 in our
via. However, it is worth noting that measurement of CL is already a com- meta-analysis was from the United
there was significant heterogeneity mon and uncomplicated measurement States.
among the included studies, particularly performed in the antepartum period,
in the definition of short CL. Some of these findings suggest that CL measure- Strengths and limitations
the studies used a cutoff of 30 mm, ment may be a valuable adjunct to clini- There are some limitations to our study.
whereas others used a cutoff of cal decision-making in managing First, the number of included studies
<25 mm. However, the subgroup analy- pregnancies with placenta previa. CL was relatively small, and the sample
sis showed that the risk of emergency >30 mm at 28 to 34 weeks of gestation sizes varied among studies. This may
CD was significantly higher regardless can serve as a reassuring indicator to have affected the generalizability of our
of the short cervix definition, suggesting inform patients that they are at reduced findings. However, the studies were per-
that CL measurement is clinically rele- risk of pregnancy complications, partic- formed in 9 different countries, and
vant in identifying pregnancies at ularly emergency delivery resulting therefore significant ethnic and cultural
increased risk of adverse outcomes from bleeding. The reported outcomes diversity was represented and may
regardless of the CL cutoff. This study in the United States differ from those in improve the extrapolation of our find-
demonstrates that a short CL in the other countries, possibly because of ings to a wide variety of patient popula-
presence of placenta previa increases studies with different qualities and tions. Second, the included studies were

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Systematic Review
FIGURE 4
Diagnostic accuracy of short CL for risk of emergency CD

A, Meta-analysis of diagnostic accuracy of short cervix for prediction of emergency cesarean delivery. B, The SROC of short cervix for prediction of emer-
gency cesarean delivery
CI: confidence interval; SROC: summary receiver-operating characteristic curve.
Hessami. Cervical length and adverse pregnancy outcome in placenta previa. Am J Obstet Gynecol MFM 2023.

10 AJOG MFM May 2024

 Systematic Review

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