Shear‐wave sonoelastographic assessment of cervix in pregnancy

The Emerging Role of Sonoelastography in Pregnancy: Applications in Assessing Maternal and Fetal Health

Sonoelastography, a novel ultrasound-based technique, is emerging as a valuable tool in prenatal diagnostics by quantifying tissue elasticity and stiffness in vivo. This narrative review explores the application of sonoelastography in assessing maternal and fetal health, with a focus on cervical, placental, pelvic floor, and fetal tissue evaluations. In the cervix, sonoelastography aids in predicting preterm birth and assessing labor induction success. For the placenta, it provides insights into conditions like preeclampsia and intrauterine growth restriction through elasticity measurements. Assessing fetal tissues, including the lungs, liver, and brain, sonoelastography offers a non-invasive method for evaluating organ maturity and detecting developmental anomalies. Additionally, pelvic floor assessments enable better management of childbirth-related injuries and postpartum recovery. While current studies support its safety when used within established limits, further research is necessary to confirm long-term effects. Future advancements include refining protocols, integrating machine learning, and combining sonoelastography with other diagnostic methods to enhance its predictive power. Sonoelastography holds promise as an impactful adjunct to conventional ultrasound, providing quantitative insights that can improve maternal and fetal outcomes in prenatal care.

Clinical experience with shear wave elastography (SWE) for assessing healthy uterus in a transabdominal approach

Aim of the study was to evaluate the diagnostic performance and feasibility of transabdominal ultrasound shear wave elastography (SWE) in assessing sonoelastographic features of the uterus. Twenty-seven premenopausal women were enrolled between 2021 and 2022. Transabdominal SWE measured myometrial stiffness in various uterine segments. Additionally, tissue stiffness of the quadriceps femoris muscle and autochthonous back muscle was measured. Statistical analysis employed non-parametric tests, t test, and a robust mixed linear model. Stiffness values of the uterus and the two investigated muscle types exhibited a similar spectrum: 6.38 ± 2.59 kPa (median 5.61 kPa; range 2.76-11.31 kPa) for the uterine myometrium, 7.22 ± 1.24 kPa (6.82 kPa; 5.11-9.39 kPa) for the quadriceps femoris musle, and 7.43 ± 2.73 kPa (7.41 kPa; 3.10-13.73 kPa) for the autochthonous back muscle. A tendency for significant differences in myometrial stiffness was observed concerning the type of labor mode (mean stiffness of 9.17 ± 1.35 kPa after vaginal birth vs. 3.83 ± 1.35 kPa after Caesarian section, p = 0.01). No significant differences in myometrial stiffness were observed concerning age, BMI, previous pregnancies, uterine flexion and menstrual cycle phase. Transabdominal SWE of uterine stiffness seems to be a fast and practicable method in a clinical setting. Uterine stiffness appears to be largely independent of various factors, except for the mode of delivery. However, further studies are needed to validate these results.

Longitudinal evaluation of cervical length and shear wave elastography in women with spontaneous preterm birth

OBJECTIVE

To evaluate longitudinal changes in cervical length (CL) and mean cervical shear wave elastography (CSWE) score in women with a singleton or twin pregnancy who undergo spontaneous preterm birth (sPTB) compared with those who deliver at term.

METHODS

This was a prospective longitudinal study of unselected women with a singleton or twin pregnancy attending a dedicated research clinic for screening for sPTB at four timepoints during pregnancy: 11 + 0 to 15 + 6 weeks, 16 + 0 to 20 + 6 weeks, 21 + 0 to 24 + 6 weeks and 28 + 0 to 32 + 6 weeks. At each visit, a transvaginal ultrasound scan was conducted to measure the CL and the CSWE scores in six regions of interest (ROI) (inner, middle and external parts of anterior and posterior cervical lips). The mean CSWE score from the six ROIs was calculated for analysis. Log10 transformation was applied to data to produce a Gaussian distribution prior to statistical analysis. A multilevel mixed-effects analysis was performed to compare longitudinally CL and CSWE between the sPTB and term-delivery groups.

RESULTS

The final cohort consisted of 1264 women, including 1143 singleton pregnancies, of which 57 (5.0%) were complicated by sPTB, and 121 twin pregnancies, of which 33 (27.3%) were complicated by sPTB. Compared to those who delivered at term, women with sPTB had a lower CL across gestation when controlling for history of cervical surgery, number of fetuses, gestational age (GA) at cervical assessment and the interaction between GA at cervical assessment and sPTB (P < 0.001). Specifically, CL in the sPTB group was significantly lower at 21 + 0 to 24 + 6 weeks (P = 0.039) and 28 + 0 to 32 + 6 weeks (P < 0.001). Twin pregnancies had significantly greater CL throughout pregnancy compared with singleton pregnancies (regression coefficient, 0.01864; P < 0.001). After adjusting for maternal age, weight, height, body mass index and GA at cervical assessment, CSWE score in the sPTB group was significantly lower compared with that in the term-delivery group across gestation (P = 0.013). However, on analysis of individual visits, CSWE score in the sPTB group was significantly lower than that in the term-delivery group only at 11 + 0 to 15 + 6 weeks (P = 0.036). There was no difference in CSWE score between singleton and twin pregnancies throughout gestation (regression coefficient, -0.00128; P = 0.937).

CONCLUSIONS

Women with sPTB have a shorter and softer cervix across gestation compared with those who deliver at term. A shorter cervix in the sPTB group is observed from the late second trimester onwards, while lower cervical stiffness in the sPTB group is observed primarily in the first trimester. CL is significantly lower in singleton pregnancies compared with twin pregnancies, while cervical stiffness does not differ between the two. Our findings indicate that the cervix tends to undergo a softening process prior to shortening in sPTB cases. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Predictive Value of Cervical Shear Wave Elastography in the Induction of Labor in Late-Term Pregnancy Nulliparous Women: Preliminary Results

The prediction of induction of labor continues to be a paradigm nowadays. Bishop Score is the traditional widely spread method but with a low reliability. Ultrasound cervical assessment has been proposed as an instrument of measurement. Shear wave elastography (SWE) should be a promising tool in the prediction of the success of labor induction in nulliparous late-term pregnancies. Ninety-two women with nulliparous late-term pregnancies who were going to be induced were included in the study. A shear wave measurement of the cervix divided into six regions (inner, middle and outer in both cervical lips), cervical length and fetal biometry was performed by blinded investigators prior to routine hand cervical assessment (Bishop Score (BS)) and induction of labor. The primary outcome was success of induction. Sixty-three women achieved labor. Nine women did not, and they underwent a cesarean section due to failure to induce labor. SWE was significantly higher in the inner part of the posterior cervix (p < 0.0001). SWE showed an area under the curve (AUC): 0.809 (0.677-0.941) in the inner posterior part. For CL, AUC was 0.816 (0.692-0.984). BS AUC was 0.467 (0.283-0.651). The ICC of inter-observer reproducibility was ≥0.83 in each region of interest (ROI). The cervix elastic gradient seems to be confirmed. The inner part of the posterior cervical lip is the most reliable region to predict induction of labor results in SWE terms. In addition, cervical length seems to be one of the most important procedures in the prediction of induction. Both methods combined could replace the Bishop Score.

Advances in the clinical application of ultrasound elastography in uterine imaging

Changes in tissue stiffness by physiological or pathological factors in tissue structure are identified earlier than their clinical features. Pathological processes such as uterine fibrosis, adenomyosis, endometrial lesions, infertility, and premature birth can manifest as tissue elasticity changes. In clinical settings, elastography techniques based on ultrasonography, optical coherence tomography, and magnetic resonance imaging are widely used for noninvasive measurement of mechanical properties in patients, providing valuable tool and information for diagnosis and treatment. Ultrasound elastography (USE) plays a critical role in obstetrics and gynecology clinical work because of its simplicity, non-invasiveness, and repeatability. This article reviews the recent progress of USE in uterine tumor diagnosis (especially early diagnosis and treatment effect evaluation), prediction of preterm birth, and intrauterine insemination. We believe that USE, especially shear wave elastography, may serve as a potential means to assess tissue stiffness, thereby improving the diagnosis and treatment of adenomyosis, fibroids, endometrial lesions, cervical cancer, and precise management of preterm birth and intrauterine insemination monitoring.

Screening for spontaneous preterm birth by cervical length and shear-wave elastography in the first trimester of pregnancy

BACKGROUND

First-trimester cervical length for the prediction of spontaneous preterm delivery remains controversial. A better method for the measurement of the first-trimester cervical length and additional cervical ultrasound parameters for the identification of women at high risk for spontaneous preterm delivery are needed.

OBJECTIVE

This study aimed to compare the predictive value of cervical length measured by 2 different methods in the first trimester of pregnancy to predict spontaneous preterm delivery and to explore the potential value of first-trimester cervical shear-wave elastography for the prediction of spontaneous preterm delivery.

STUDY DESIGN

This was a prospective study in unselected singleton pregnancies at 11⁺⁰ to 13⁺⁶ weeks' gestation. Cervical length was measured by the following 2 methods in the base-cohort population: (1) a linear distance between the 2 ends of the glandular area around the endocervical canal (single-line method: cervical length-s) and (2) a sum of the linear distance from the internal os to the greatest cervical curvature and the linear distance from this point to the external os (2-line method: cervical length-t). In a substudy, cervical shear-wave elastography scores for 9 regions of interest (inner, middle, and external parts of anterior lip, endocervical canal, and posterior lip) in midsagittal plane were also obtained by transvaginal ultrasonography. The screening performance of the first-trimester cervical length measured by the 2 different methods for the prediction of spontaneous preterm delivery was assessed by receiver operating characteristics curve analysis. The areas under the curves were compared using a DeLong test. The predictive performance of a soft cervix (mean elastography scores with multiple of median <5th, 10th, 15th, 20th, and 25th percentile) for spontaneous preterm delivery was also determined.

RESULTS

Among a total of 2316 included pregnancies, spontaneous delivery at <37 and <34 weeks' gestation occurred in 111 cases (4.8%) and 20 cases (0.9%), respectively. In the total study population, when compared with the term delivery group, the median cervical length-t was shorter in women with spontaneous delivery at <34 weeks' gestation (36.9 mm vs 35.1 mm; P=.015), but there was no clear correlation for cervical length-s. Receiver operating characteristics curves demonstrated that cervical length-t achieved better performance in predicting spontaneous delivery at <34 weeks' gestation (area under the curve, 0.658 vs 0.573; P<.01) than cervical length-s. The best combined model to predict spontaneous delivery at <34 weeks' gestation was provided by cervical length-t and history of preterm delivery (area under the curve, 0.692). In the substudy, a soft cervix with a mean elastography scores multiple of median <10th percentile had a relative risk of 7.8 (95% confidence interval, 2.1-28.6) for spontaneous delivery at <34 weeks' gestation; the detection rate was 44.4% at a false-positive rate of 9.0%.

CONCLUSION

The 2-line approach provides a better estimate of the actual first-trimester cervical length and achieves better performance as a screening tool for spontaneous preterm delivery at <34 weeks' gestation than the conventional measurement. A soft cervix as determined by shear-wave elastograpthy in the first trimester is associated with an increased risk for subsequent spontaneous preterm delivery.

Clinical application of cervical shear wave elastography in predicting the risk of preterm delivery in DCDA twin pregnancy

Background

Limited studies have used cervical shear wave elastography (SWE) as a tool to investigate the predictive effect of cervical changes on preterm delivery (PTD) in twin pregnancy. This study is aimed to predict the risk of PTD by cervical SWE in dichorionic diamniotic (DCDA) twin pregnancy.

Methods

A total of 138 women with dichorionic diamniotic (DCDA) twins were included in this prospective study. The mean SWE value of the cervix was obtained from the inner, middle and outer regions of the anterior and posterior cervical lips using a transvaginal ultrasound transducer and measured consecutively across three different gestations (20–23^+ 6 weeks, 24–27^+ 6 weeks, and 28–32 weeks). Follow-up was performed on all subjects, and we compared the mean SWE value between the PTD and term delivery (TD) groups.

Results

A total of 1656 cervical mean SWE data were collected for analysis. Among the 138 twin pregnant women, only 92 women completed the three elastography examinations; PTD occurred in 58.7% (54/92), and TD in 41.3% (38/92). The mean (SD) maternal age was 33.1 ± 4.1 years, and the mean (SD) body mass index was 21.1 ± 2.6 kg/m². As gestational age increased, the mean SWE value of each part of the cervix decreased. The cervical mean SWE value was lower in the preterm group than in the term group in all three gestations, except for the anterior cervical lip at 28–32 weeks. Receiver operating characteristics (ROC) curves showed the sensitivity of mean SWE value of the anterior cervical lip was 83.3% (95% CI, 70.7–92.1) with a specificity of 57.9% (95% CI, 40.8–73.7) for predicting PTD at a cutoff value of 7.94 kPa. The positive likelihood ratio (LR+) was 1.67 (95% CI, 1.19–2.34), and the negative likelihood ratio (LR–) was 0.33 (95% CI, 0.17–0.64).

Conclusions

There is a significant negative correlation between cervical stiffness and gestational age in DCDA twin pregnancy. SWE is a potential tool for assessing cervical stiffness and predicting PTD in DCDA twin pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04526-0.

Evaluation of Pre-malignant Lesions of the Uterine Cervix by Shear Wave Elastography: A New Diagnostic Tool

The objective of the study was to evaluate the difference in the stiffness between a healthy cervix (no pre-invasive lesions [NPILs]) and a cervix with a pre-invasive lesion (PIL). In the PIL group, we determined whether there was a difference in stiffness between the cervix with persistent low-grade lesions (>2 y, LSIL-persistent) and that with high-grade lesions (HSILs). Evaluation was performed using 2-D shear-wave elastography (SWE) in the midsagittal-plane of the uterine cervix (UC) at 0.5 cm (cervical canal, anterior and posterior cervical lips). In this prospective observational study (consecutive series), we evaluated 96 non-pregnant women: a group with PIL (LSIL-persistent, 22 cases; HSIL, 26 cases) with indications for cervical conization (48 cases) and a group without UC pathology (NPIL, 48 cases). Although we did not observe statistically significant differences (SSDs) in epidemiological characteristics, we did find an SSD in the speed and stiffness between the PIL versus NPIL groups at all evaluated depths (speed: 4.1 m/s vs 3.0 m/s, stiffness: 58.6 and 34.5kPa in the PIL and NPIL groups, respectively, p < 0.001). An SSD in speed and stiffness (speed: 4.9 m/s vs. 3.2 m/s, and stiffness: 76.1 and 38.0 kPa) between the HSIL (26 cases) and LSIL-persistent (22 cases) groups, respectively, was also detected (p < 0.001). The area under the curve of speed differentiation between a cervix with HSILs and without lesions was 73.4% (95% confidence interval [CI]: 63.1-83.7), and the best cutoff of speed was 3.25 m/s (sensitivity = 62.5%, 95% CI: 47.3-76.0), with a specificity of 75.5% (95% CI: 60.4-87.1).

Temperature Elevation in an Instrumented Phantom Insonated by B-Mode Imaging, Pulse Doppler and Shear Wave Elastography

Diagnostic ultrasound is the gold standard for obstetric scanning and one of the most important imaging techniques for perinatal and neonatal monitoring and diagnosis. Ultrasound provides detailed real-time anatomic information, including blood flow measurements and tissue elasticity. The latter is provided through various techniques including shear wave elastography (SWE). SWE is increasingly used in many areas of medicine, especially in detection and diagnosis of breast, thyroid and prostate cancers and liver disease. More recently, SWE has found application in gynaecology and obstetrics. This method mimics manual palpation, revealing the elastic properties of soft biological tissues. Despite its rising potential and expanding clinical interest in its use in obstetrics and gynaecology (such as for assessment of cervical ripening or organ development and structure during pregnancy), its effects on and potential risks to the developing fetus remain unknown. Risks should be evaluated by regulatory bodies before recommendations are made on the use of SWE. Because ultrasound is known to produce thermal and mechanical effects, this study measured the temperature increase caused by B-mode, pulse Doppler (PD) and SWE, using an instrumented phantom with 11 embedded thermocouples. Experiments were performed with an Aixplorer diagnostic ultrasound system (Supersonic Imagine, Aix-en-Provence, France). As expected, the greatest heating was detected by the thermocouple closest to the surface in contact with the transducer (2.9°C for SWE, 1.2°C for PD, 0.7°C for B-mode after 380-s excitation). Both conduction from the transducer face and direct heating owing to ultrasound waves contribute to temperature increase in the phantom with SWE associated with a larger temperature increase than PD and B-mode. This article offers a methodological approach and reference data for future safety studies, as well as initial recommendations about SWE safety in obstetrics and gynaecology.