Predictive performance of cervical elastography for preterm birth: A head-to-head network meta-analysis

doi:10.4329/wjr.v18.i5.119213

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World Journal of Radiology

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1949-8470

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Meta-Analysis

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Radiol. May 28, 2026; 18(5): 119213
Published online May 28, 2026. doi: 10.4329/wjr.v18.i5.119213

Predictive performance of cervical elastography for preterm birth: A head-to-head network meta-analysis

Hui-Ping Zhang, Na Li, Fan Li, Yu-Qing Zhou

Hui-Ping Zhang, Yu-Qing Zhou, Department of Ultrasound in Obstetrics and Gynecology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200336, China

Na Li, School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China

Fan Li, Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China

Co-first authors: Hui-Ping Zhang and Na Li.

Co-corresponding authors: Fan Li and Yu-Qing Zhou.

Author contributions: Zhang HP and Li N performed data extraction, contributed to data analysis tools, quality assessment, and wrote the manuscript, and they contributed equally to this work as co-first authors; Zhang HP, Li F, and Zhou YQ analyzed the data; Li F and Zhou YQ contributed equally to this work as co-corresponding authors. All authors designed the research study and all authors have read and approved the final manuscript.

Supported by Key Specialty of Changning District, Shanghai, China, No. 20231004.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Yu-Qing Zhou, MD, Professor, Department of Ultrasound in Obstetrics and Gynecology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, No. 1111 Xianxia Road, Shanghai 200336, China. doczhou@qq.com

Received: January 22, 2026
Revised: March 2, 2026
Accepted: April 7, 2026
Published online: May 28, 2026
Processing time: 125 Days and 23 Hours

Abstract

BACKGROUND

Early detection of cervical remodeling is vital for predicting preterm birth (PTB). Conventional morphologic indices, such as cervical length (CL) and anterior cervical angle (ACA), demonstrate limited diagnostic accuracy. Elastic imaging of the cervix (E-cervix) elastography offers functional biomechanical insights by quantifying cervical strain and stiffness. However, a systematic comparison of its diverse parameters alongside traditional indices is currently lacking. Identifying the most effective ultrasound-based markers is essential for improving mid-trimester risk stratification and facilitating timely clinical interventions to improve perinatal outcomes.

AIM

To evaluate and compare the diagnostic performance of E-cervix parameters, CL, and ACA for PTB.

METHODS

PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were searched up to December 1, 2025. Studies reporting diagnostic accuracy of E-cervix parameters, CL, or ACA for PTB were included. A Bayesian network meta-analysis estimated pooled sensitivity, specificity, and diagnostic odds ratios (DOR). The comparative performance was ranked using the advantage index. Heterogeneity was assessed via Cochran’s Q and I² statistics, with meta-regression exploring potential modifiers.

RESULTS

Fifteen studies involving 1965 pregnancies (570 PTB cases) were included. The multi-parametric combined model demonstrated the highest diagnostic performance, with an area under the curve of 0.91, sensitivity of 0.83, specificity of 0.83, and a DOR of 26.23. Among individual parameters, ACA (DOR: 13.65) and the E-cervix hardness ratio (DOR: 7.71) significantly outperformed conventional CL (DOR: 3.58). Subgroup analysis revealed that the combined model was particularly effective in singleton pregnancies (sensitivity: 0.837, specificity: 0.882). No significant publication bias was detected except for elasticity contrast index.

CONCLUSION

E-cervix elastography provides superior diagnostic value compared to conventional CL measurement. The integration of biomechanical and morphological data via multi-parametric models offers the most precise risk stratification for PTB.

Keywords: Preterm birth; Cervical length; Cervical elastography; Elastic imaging of the cervix; Hardness ratio; Network meta-analysis

Core Tip: Cervical length and anterior cervical angle are widely used to assess preterm birth risk; however, they overlook early biomechanical remodeling. By synthesizing 15 studies, this head-to-head Bayesian network meta-analysis demonstrates that cervical elastography, particularly the hardness ratio, enhances discrimination, and that combined morphologic-biomechanical models achieve the best overall accuracy. These results support the integration of cervical elastography into risk stratification and highlight the need for standardized protocols and thresholds.