Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Series
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Education, Original Research
Emergency, Original Research
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Research
Original Research Article
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
Radiologic-Pathologic Correlation
Radiology Business, Original Research
Research Article
Review Article
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research
View/Download PDF

Translate this page into:


Association of Progesterone, Pessary, and Antibiotic for Treating Pregnant Woman with Short Cervix Syndrome: Importance of Magnetic Resonance Imaging in the Assessment of Pessary Position

Department of Obstetrics, Federal University of São Paulo, São Paulo-SP, Brazil
Address for correspondence: Prof. Edward Araujo Júnior, Department of Obstetrics, Federal University of São Paulo, Rua Carlos Weber, 956, Apt. 113 Visage, Vila Leopoldina, São Paulo – SP, CEP 05303-000, Brazil. E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.

Source of Support: Nil

Conflict of Interest: None declared.


Preterm delivery (PD) is the most important cause of neonatal mortality, particularly before the 32nd week of pregnancy. A short cervix is the most important quantitative marker for predicting PD. However, there are other qualitative markers such as cervical gland area, cervical funneling, and sludge. We present the case of a pregnant woman who was diagnosed with a short cervix at 14-weeks and demonstrate the use of triple therapy, which helped to achieve a good perinatal result. A 37-year-old pregnant woman (G3P0) was referred to our service at 14-weeks of pregnancy presenting with a short cervix (20 mm) and a positive sludge sign. She was hospitalized; a pessary was inserted, and started on antibiotic therapy (clindamycin and cefalotin for 10 days). At 20 weeks, she was again admitted to the hospital, and this time presented with a further shortened cervix (9 mm), cervical funneling, and a positive sludge sign, with the pessary in position. The following procedures were performed: Amniocentesis on the sludge (negative bacterioscopy), another cycle of antibiotics, administration of oral progesterone, and imaging to determine retention of pessary position. The patient was placed in the Trendelenburg position and remained hospitalized for 82 days. At 32 + 1 weeks, the fetus presented distress (tachycardia). C-section was performed, producing a live female newborn weighing 2,180 g and presenting Apgar indexes of 8/8. This case report demonstrates the importance of magnetic resonance imaging to assess the position of pessary in a pregnant woman with short cervix.


Magnetic resonance imaging
preterm delivery
short cervix syndrome


Preterm delivery (PD) is one of the most serious public health problems and an important morbidity and mortality factor during the neonatal period. It is defined as interruption of pregnancy before 37 weeks have been completed, and the morbidity and mortality become significantly higher when delivery takes place before the 32nd week.[1] Its incidence rate is variable: In Europe, it ranges from 6% to 10%, while in the United States, it increased from 9.5% in 1981 to 12-13% in 2005.[2]

Etiology of PD often cannot be defined and idiopathic causes account for 20% to 40% of the cases.[3] It is now understood that the process should be interpreted as a multifactorial syndrome, in which several excitatory mechanisms are involved. Studies conducted around 15 years ago found a correlation between shortening of the cervix, as detected using transvaginal ultrasonography (TVUS) and PD.[4] Recently, some trials have confirmed that progesterone and a pessary are effective in preventing PD among high-risk women.[56] Because of a hypothesis that early shortening of the cervix results from intra-amniotic infection,[7] and that its ultrasonographic representation is the sludge sign,[8] use of antibiotics might become a new form of therapy for short cervix syndrome. On the other hand, there have not yet been any trials confirming their efficacy.

We present a case of a pregnant woman who was diagnosed with the short cervix syndrome in the 14th week, in which use of progesterone, pessary, and antibiotic changed the natural history of fetal viability. We emphasize the importance of magnetic resonance imaging (MRI) in the assessment of pessary position.


A married white pregnant woman who was nulliparous, and in her third pregnancy, was referred to our service at the gestational age of 14 weeks and 4 days due to shortening of the cervix (20 mm) and the presence of a positive sludge sign. Among her obstetric antecedents, she said that she had two early spontaneous abortions (8 weeks). The patient was hospitalized at our institute. A pessary was placed in the cervix, and antibiotic therapy consisting of clindamycin (600 mg IV, every 8 h) and cefalotin (1 g IV, every 6 h) was administered for 10 days. The patient was then released from hospital, but returned in the 20th week presenting a cervical length of 9 mm, cervical funneling, positive sludge sign, and absence of cervical gland area (CGA) as seen on Transvaginal ultrasonography (TVUS) that was performed. TVUS confirmed that the pessary was in position [Figure 1]. It was decided to hospitalize the patient again, and amniocentesis was performed on the sludge, which gave negative bacterioscopy results. A new cycle of antibiotic therapy consisting of clindamycin and cefalotin was instituted, and natural progesterone was administered orally (200 mg every 12 h). The patient was placed in the Trendelenburg posture, and the vaginal pessary was maintained in position. During this hospital stay, the patient was also treated for two urinary tract infections: First with cefalexin (500 mg orally every 8 h for 10 days); and the second with ceftriaxone (1 g IV every 12 h for 10 days. Enoxaparin (40 mg/day IM) was introduced, along with two cycles of corticoid induction consisting of betamethasone (12 mg/day IM for two days). During the hospital stay, because of the difficulty in assessing the pessary by means of TVUS, it was decided to perform MRI on the pelvis, which proved that the pessary was in the normal position [Figure 2]. The patient remained hospitalized for 82 days and, in the 32nd week of the pregnancy, she developed a condition of maternal and fetal tachycardia. Resolution of the gestation was thus indicated due to acute fetal distress. A transverse segmental cesarean delivery was then performed, which produced a live female newborn weighing 2,180 g and presenting Apgar scores of 8/8 in the first and fifth minutes, respectively. The mother progressed well during the puerperium period and was released from hospital 72 hours after the delivery. The newborn presented slight respiratory discomfort but did not require orotracheal intubation or vasoactive drugs. The infant was kept in the neonatal intensive care unit for 75 days and did not present any serious complications. Currently, the infant is in a good general condition, without any neuropsychomotor sequelae.

Figure 1: Caucasian female at 20 weeks of pregnancy with short cervix (9.0 mm). Transvaginal ultrasonogra phy in the sagittal plane, shows the funneling sign (A), absence of cervical gland area, and presence of normally positioned pessary (white arrows). IO: Internal orifice.
Figure 2: Caucasian female with short cervix (9.0 mm). Magnetic resonance imaging on the pelvis. (a) T2 view in the sagittal plane shows the normally positioned pessary (white arrows). (b) T2 view in the axial plane, shows the pessary with its classical circular shape with serrated edges (white arrows). IO: Internal orifice. CP: Cephalic pole.


We present a case in which triple therapy consisting of progesterone, pessary, and antibiotic turned an unviable pregnancy into a good perinatal result.

Preterm delivery (PD) is the main cause of perinatal morbidity and mortality worldwide, particularly when this occurs before the 32nd week of pregnancy. The etiology is multifactorial, but all such conditions progress with dilatation and disappearance of the cervix. A clinical history of previous PD, together with a short cervix (usually less than 25 mm, as measured on TVUS between the 20th and 24th weeks), is the main method of identifying women who are at high risk of PD. However, some authors have advocated that measurements of the cervix should be made universally between the 20th and 24th weeks, because 85% of PDs occur in women without risk factors.[9]

In this study, the woman presented with a short cervix at 14 weeks of pregnancy; we needed to repeat the antibiotic therapy at 20 weeks because the cervix had further shortened (20 mm at 14 weeks to 9 mm at 20 weeks). The next set of antibiotics was used only to treat the urinary tract infection that the patient developed and they were not part of triple treatment protocol.

The amniocentesis of sludge was performed at 20 weeks of pregnancy, because of high risk of pregnancy loss when it is done before 16 weeks. The sludge is a sign seen in an ultrasound scan that demonstrates a thick material with particles in suspension. The negative bacterioscopy does not necessarily exclude the presence of infection. It would be necessary to perform polymerase chain reaction (PCR) to identify the microorganisms involved in the infection, but this process is very expensive and it is not performed in our routine protocol. Previous study has demonstrated that sludge is associated with positive amniotic fluid cultures and histological chorioamnionitis.[9] The antibiotic protocol of our Department to prevent the preterm delivery in pregnant women with short cervix is a combination of clindamic and cefalotin an approach to combat all possible microorganisms. We carried out bacterioscopy at 20 weeks to find possible resistant strains of microorganisms, but this result was negative; we decided to repeat the same combination of antibiotics.

In addition to measurements of the cervix, which is a quantitative parameter, there are qualitative parameters such as the funneling sign, sludge sign, and absence of the CGA.[810] The funneling sign represents early opening of the internal orifice of the cervix, with protrusion of the membranes, at rest or with abdominal pressure. However, much controversy surrounds this sign in the literature. Absence of the CGA, which was studied in Brazil by Pires et al.,[10] corresponds to absence of the cervical gland area around the cervical canal and, according to these authors, is more associated with the risk of PD than with a short cervix and the funneling sign. When the CGA is associated with a short cervix of 9.0 mm as in this pregnant woman, the risk of PD is higher. The sludge corresponds to an agglomeration of hyperechogenic particles located between the internal orifice and the fetal presentation, and which are deposited on the posterior wall of the cervix. An association between sludge and a short cervix confers greater risk of PD than does a short cervix alone.[8]

Progesterone and, more recently, pessaries are among the methods used for preventing PD.[56] Progesterone relaxes the musculature of the myometrium and blocks the action of oxytocin. Vaginal administration provides greater concentrations in the endometrium, but in women at high risk of PD, systemic administration is preferred. With regard to pessaries, in a recent randomized clinical study on 393 women with a short cervix, of whom 192 had a pessary out of 193 who were expectant, giving birth before the 34th week occurred significantly less frequently in the group with a pessary (6% vs. 27%).[6] Use of antibiotic therapy has been based on the fact that the sludge is associated with clinical and histological chorioamnionitis and with positive cultures from the amniotic fluid.[8] However, no randomized clinical trials proving the efficacy of antibiotic therapy among women at high risk of PD have yet been produced.

In this case, we presented images of the pessary obtained by means of TVUS and MRI. TVUS is the routine method for assessing the position of the pessary, since clinical examination presents a high risk of triggering PD. However, in some situations, it is difficult to prove the diagnosis using TVUS. In such cases, MRI is indicated. This is a harmless examination during pregnancy, and its only contraindications are claustrophobia and presence of metallic implants. The image of the pessary that we presented here is a novel feature in the literature. It allowed us to prove that the pessary was in the normal position, which in turn was fundamental for the good perinatal result.

In patients with high risk preterm deliveries as the patient of case report, the digital exam of cervix is dangerous. The MRI is an innocuous and safe exam to these patients; moreover, it permits to identify the correct position of pessary. The digital exam should only to be realized in patients with active preterm delivery.

In summary, we presented a case of a pregnant woman with short cervix syndrome who was treated using a triple regimen (progesterone, pessary, and antibiotic). The good perinatal result obtained in this case opens up the prospect of future randomized clinical trials that might be capable of proving what the real efficacy of this regimen is, in relation to single-track regimens. MRI was shown to be an effective imaging method for evaluating the position of the pessary, and it can be chosen as the method for cases, in which TVUS is seen to be inconclusive.


We believe that the association of progesterone, antibiotic, and pessary may change the concept of fetal viability among women who are at high risk of PD, when instituted early on during the pregnancy. The MRI showed to be an effective imaging method to assess the pessary position in a pregnant woman with short cervix.


  1. , , , . Preterm delivery: An overview. Acta Obstet Gynecol Scand. 2003;82:687-704.
    [Google Scholar]
  2. , , . The prevention of premature birth. N Engl J Med. 1998;339:313-20.
    [Google Scholar]
  3. , . Some thoughts on the true value of ultrasound. Ultrasound Obstet Gynecol. 2007;30:671-4.
    [Google Scholar]
  4. , , , , , , . The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl Med J. 1996;334:567-72.
    [Google Scholar]
  5. , , , , , . Progesterone and the risk of preterm among women with a short cervix. N Engl J Med. 2007;357:462-9.
    [Google Scholar]
  6. , , , , , , . Cervical pessary in pregnant women with a short cervix (PECEP): An open-label randomised controlled trial. Lancet. 2012;379:1800-6.
    [Google Scholar]
  7. , , , , . The role of infection in preterm birth. J Gynecol Obstet Biol Reprod (Paris). 2012;41:14-25.
    [Google Scholar]
  8. , , , , , , . The prevalence and clinical significance of amniotic fluid ‘sludge’ in patients with preterm labor and intact membranes. Ultrasound Obstet Gynecol. 2005;25:346-52.
    [Google Scholar]
  9. , , , . A short cervical length in pregnancy: Management options. Am J Perinatol. 2009;26:761-70.
    [Google Scholar]
  10. , , , , , , . Cervical gland area as an ultrasonographic marker for preterm delivery. Int J Gynaecol Obstet. 2006;93:214-9.
    [Google Scholar]
Show Sections