Advertisement

Use of cervical elastography at 18 to 22 weeks’ gestation in the prediction of spontaneous preterm birth

      Background

      Accurate identification of the women who will have spontaneous preterm birth continues to be a great challenge. The use of cervical elastography for prediction of preterm birth is promising, but several limitations exist. Newer cervical elastography technology has been developed that may prove useful in evaluation of risk of preterm birth.

      Objective

      This study aimed to develop standard cervical elastography nomograms for singleton pregnancies at 18 to 22 weeks’ gestation using the E-Cervix ultrasound application, assess intraobserver reliability of the E-Cervix elastography parameters, and determine whether these cervical elastography measurements can be used in the prediction of spontaneous preterm birth.

      Study Design

      This was a prospective cohort study of pregnant women undergoing cervical length screening assessment via transvaginal ultrasound examination at 18 to 22 weeks’ gestation. A semiautomatic, cervical elastography application (E-Cervix) was used during the transvaginal examination to calculate 5 quantitative parameters (internal os stiffness, external os stiffness, internal -to -external os stiffness ratio, hardness ratio, and elasticity contrast index) and create a standard nomogram for each one of them. The intraobserver reliability was calculated using Shrout-Fleiss reliability. Cervical elastography parameters were compared between those who delivered preterm (<37 weeks) spontaneously and those who delivered full term. A multivariable logistic regression model was performed to determine the ability of the cervical elastography parameters to predict spontaneous preterm birth.

      Results

      A total of 742 women were included, of which 49 (6.6%) had a spontaneous preterm delivery. A standard nomogram was created for each of the cervical elastography parameters from those who had a full-term birth in the index pregnancy (n=693). Intraobserver reliability was good or excellent (intraclass correlation, 0.757–0.887) for each of the cervical elastography parameters except external os stiffness which was poor (intraclass correlation, 0.441). In univariate analysis, none of the cervical elastography parameters were associated with a statistically significant increased risk of spontaneous preterm birth. In a multivariable model adjusting for history of preterm birth, gravidity, ethnicity, cervical cerclage, and vaginal progesterone use, increasing elasticity contrast index was significantly associated with an increased risk of spontaneous preterm birth (odds ratio, 1.15; 95% confidence interval, 1.02–1.30; P=.02).

      Conclusion

      Cervical elastography parameters are reliably measured and are stable across 18 to 22 weeks’ gestation. Based on our findings, the elasticity contrast index was associated with an increased risk of spontaneous preterm birth and may be a useful parameter for future research.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Conde-Agudelo A.
        • Romero R.
        • Da Fonseca E.
        • et al.
        Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: updated indirect comparison meta-analysis.
        Am J Obstet Gynecol. 2018; 219: 10-25
        • Conde-Agudelo A.
        • Romero R.
        • Nicolaides K.H.
        Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis.
        Am J Obstet Gynecol. 2020; 223: 42-65.e2
        • Cobo T.
        • Aldecoa V.
        • Figueras F.
        • et al.
        Development and validation of a multivariable prediction model of spontaneous preterm delivery and microbial invasion of the amniotic cavity in women with preterm labor.
        Am J Obstet Gynecol. 2020; 223: 421.e1-421.e14
        • Merced C.
        • Goya M.
        • Pratcorona L.
        • et al.
        Cervical pessary for preventing preterm birth in twin pregnancies with maternal short cervix after an episode of threatened preterm labor: randomised controlled trial.
        Am J Obstet Gynecol. 2019; 221: 55.e1-55.e14
        • Gudicha D.W.
        • Romero R.
        • Kabiri D.
        • et al.
        Personalized assessment of cervical length improves prediction of spontaneous preterm birth: a standard and a percentile calculator.
        Am J Obstet Gynecol. 2021; 224: 288.e1-288.e17
        • Nelson D.B.
        • McIntire D.D.
        • Leveno K.J.
        A chronicle of the 17-alpha hydroxyprogesterone caproate story to prevent recurrent preterm birth.
        Am J Obstet Gynecol. 2021; 224: 175-186
        • Society for Maternal-Fetal Medicine publications committee. Electronic address: [email protected]
        SMFM Statement: use of 17-alpha hydroxyprogesterone caproate for prevention of recurrent preterm birth.
        Am J Obstet Gynecol. 2020; 223: B16-B18
        • Okitsu O.
        • Mimura T.
        • Nakayama T.
        • Aono T.
        Early prediction of preterm delivery by transvaginal ultrasonography.
        Ultrasound Obstet Gynecol. 1992; 2: 402-409
        • Mella M.T.
        • Berghella V.
        Prediction of preterm birth: cervical sonography.
        Semin Perinatol. 2009; 33: 317-324
        • Vintzileos A.M.
        • Visser G.H.
        Interventions for women with mid-trimester short cervix: which ones work?.
        Ultrasound Obstet Gynecol. 2017; 49: 295-300
        • Chen C.Y.
        • Chen C.P.
        • Sun F.J.
        Assessment of the cervix in pregnant women with a history of cervical insufficiency during the first trimester using elastography.
        Acta Obstet Gynecol Scand. 2020; 99: 1497-1503
        • Gesthuysen A.
        • Hammer K.
        • Möllers M.
        • et al.
        Evaluation of cervical elastography strain pattern to predict preterm birth.
        Ultraschall Med. 2020; 41: 397-403
        • Hernandez-Andrade E.
        • Garcia M.
        • Ahn H.
        • et al.
        Strain at the internal cervical os assessed with quasi-static elastography is associated with the risk of spontaneous preterm delivery at ≤34 weeks of gestation.
        J Perinat Med. 2015; 43: 657-666
        • Hernandez-Andrade E.
        • Maymon E.
        • Luewan S.
        • et al.
        A soft cervix, categorized by shear-wave elastography, in women with short or with normal cervical length at 18-24 weeks is associated with a higher prevalence of spontaneous preterm delivery.
        J Perinat Med. 2018; 46: 489-501
        • Hernandez-Andrade E.
        • Romero R.
        • Korzeniewski S.J.
        • et al.
        Cervical strain determined by ultrasound elastography and its association with spontaneous preterm delivery.
        J Perinat Med. 2014; 42: 159-169
        • Köbbing K.
        • Fruscalzo A.
        • Hammer K.
        • et al.
        Quantitative elastography of the uterine cervix as a predictor of preterm delivery.
        J Perinatol. 2014; 34: 774-780
        • Oturina V.
        • Hammer K.
        • Möllers M.
        • et al.
        Assessment of cervical elastography strain pattern and its association with preterm birth.
        J Perinat Med. 2017; 45: 925-932
        • Du L.
        • Zhang L.H.
        • Zheng Q.
        • et al.
        Evaluation of cervical elastography for prediction of spontaneous preterm birth in low-risk women: a prospective study.
        J Ultrasound Med. 2020; 39: 705-713
        • Park H.S.
        • Kwon H.
        • Kwak D.W.
        • et al.
        Addition of cervical elastography may increase preterm delivery prediction performance in pregnant women with short cervix: a prospective study.
        J Korean Med Sci. 2019; 34: e68
        • Suthasmalee S.
        • Moungmaithong S.
        Cervical shear wave elastography as a predictor of preterm delivery during 18-24 weeks of pregnancy.
        J Obstet Gynaecol Res. 2019; 45: 2158-2168
        • Wozniak S.
        • Czuczwar P.
        • Szkodziak P.
        • Milart P.
        • Wozniakowska E.
        • Paszkowski T.
        Elastography in predicting preterm delivery in asymptomatic, low-risk women: a prospective observational study.
        BMC Pregnancy Childbirth. 2014; 14: 238
        • Woźniak S.
        • Czuczwar P.
        • Szkodziak P.
        • Wrona W.
        • Paszkowski T.
        Elastography for predicting preterm delivery in patients with short cervical length at 18-22 weeks of gestation: a prospective observational study.
        Ginekol Pol. 2015; 86: 442-447
        • Feltovich H.
        • Hall T.J.
        • Berghella V.
        Beyond cervical length: emerging technologies for assessing the pregnant cervix.
        Am J Obstet Gynecol. 2012; 207: 345-354
        • Wang B.
        • Zhang Y.
        • Chen S.
        • et al.
        Diagnostic accuracy of cervical elastography in predicting preterm delivery: a systematic review and meta-analysis.
        Medicine (Baltimore). 2019; 98: e16449
        • Seol H.J.
        • Sung J.H.
        • Seong W.J.
        • et al.
        Standardization of measurement of cervical elastography, its reproducibility, and analysis of baseline clinical factors affecting elastographic parameters.
        Obstet Gynecol Sci. 2020; 63: 42-54
        • Du L.
        • Lin M.F.
        • Wu L.H.
        • et al.
        Quantitative elastography of cervical stiffness during the three trimesters of pregnancy with a semiautomatic measurement program: a longitudinal prospective pilot study.
        J Obstet Gynaecol Res. 2020; 46: 237-248
        • Zhou Y.
        • Jin N.
        • Chen Q.
        • et al.
        Predictive value of cervical length by ultrasound and cervical strain elastography in labor induction at term.
        J Int Med Res. 2021; 49300060520985338
        • Jung Y.J.
        • Kwon H.
        • Shin J.
        • et al.
        The feasibility of cervical elastography in predicting preterm delivery in singleton pregnancy with short cervix following progesterone treatment.
        Int J Environ Res Public Health. 2021; 18: 2026
      1. Perinatal Quality Foundation. Cervical Length Education and Review. 2020. Available at: https://clear.perinatalquality.org. Accessed July 2, 2021.

        • Rizzo G.
        • Pietrolucci M.E.
        • Mappa I.
        • et al.
        Sonoelastographic assessment of the uterine cervix in the prediction of imminent delivery in singleton nulliparous women Near term: a prospective cohort study.
        J Ultrasound Med. 2021; 40: 559-568
        • Shrout P.E.
        • Fleiss J.L.
        Intraclass correlations: uses in assessing rater reliability.
        Psychol Bull. 1979; 86: 420-428
        • King J.E.
        Running a best-subsets logistic regression: an alternative to stepwise methods.
        Educ Psychol Meas. 2003; 63: 392-403
        • Zhang L.
        • Zheng Q.
        • Xie H.
        • Du L.
        • Wu L.
        • Lin M.
        Quantitative cervical elastography: a new approach of cervical insufficiency prediction.
        Arch Gynecol Obstet. 2020; 301: 207-215
        • Kwak D.W.
        • Kim M.
        • Oh S.Y.
        • et al.
        Reliability of strain elastography using in vivo compression in the assessment of the uterine cervix during pregnancy.
        J Perinat Med. 2020; 48: 256-265
        • Fruscalzo A.
        • Londero A.P.
        • Fröhlich C.
        • Möllmann U.
        • Schmitz R.
        Quantitative elastography for cervical stiffness assessment during pregnancy.
        BioMed Res Int. 2014; 2014: 826535