Composite sonographic assessment of cervical insufficiency and risk of severe prematurity: a retrospective cohort study

Abstract Purpose To evaluate a composite ultrasound cervical score integrating multiple sonographic markers of cervical disease severity and assess its association with severe prematurity and neonatal outcomes. As a secondary exploratory objective, we investigated whether triple antibiotic therapy influenced outcomes according to risk stratification. Methods This retrospective cohort study included women with cervical insufficiency managed at a tertiary referral center between January 2019 and December 2023. All patients underwent transvaginal ultrasound assessment at admission. A composite cervical score (range 0–4) was developed by assigning one point for each abnormal parameter: cervical shortening, cervical funneling, intra-amniotic sludge, and fetal membrane prolapse. Patients were stratified into low-risk (score < 2) and high-risk (score ≥ 2) groups. The primary outcome was delivery at or beyond 32 weeks of gestation. Secondary outcomes included gestational age at delivery, neonatal birthweight, NICU admission, and neonatal morbidity. Multivariable logistic regression was performed adjusting for maternal age, gestational age at admission and previous preterm birth. Results Fifty-seven women were included. Median gestational age at admission was 22 weeks (IQR 20–23), and 61% had a score ≥ 2. Women with a high-risk score were significantly less likely to deliver at or beyond 32 weeks of gestation than those with a low-risk score (34% vs. 82%, p < 0.001). Although high-risk women showed numerically higher rates of NICU admission, respiratory morbidity, bronchopulmonary dysplasia, and lower birthweight, these differences did not reach statistical significance. After adjustment for maternal age, gestational age at admission, and previous preterm birth, a score ≥ 2 remained independently associated with a lower likelihood of delivery at or beyond 32 weeks (OR 0.12, 95% CI 0.03–0.44; p = 0.003). Triple antibiotic therapy was not associated with significant improvements in obstetric or neonatal outcomes. Conclusions A composite ultrasound cervical score integrating four sonographic markers of cervical disease severity was independently associated with severe prematurity in women with cervical insufficiency. Although neonatal morbidity tended to be higher among women with high-risk scores, these differences were not statistically significant. If externally validated, this simple ultrasound-based score may improve risk stratification and support individualized clinical management.