Reliability of strain elastography using in vivo compression in the assessment of the uterine cervix during pregnancy

Dong Wook Kwak
  • Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, The Republic of Korea
  • Department of Obstetrics and Gynecology, Cheil General Hospital and Women’s Healthcare Center, Seoul, The Republic of Korea
  • Search for other articles:
  • degruyter.comGoogle Scholar
, Mina Kim
  • Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
  • Search for other articles:
  • degruyter.comGoogle Scholar
, Soo-young Oh
  • Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
  • Search for other articles:
  • degruyter.comGoogle Scholar
, Hyun Soo Park
  • Department of Obstetrics and Gynecology, Graduate School of Medicine, Dongguk University, Seoul, The Republic of Korea
  • Search for other articles:
  • degruyter.comGoogle Scholar
, Sa Jin Kim
  • Department of Obstetrics and Gynecology, College of Medicine, The Catholic University of Korea, Seoul, The Republic of Korea
  • Search for other articles:
  • degruyter.comGoogle Scholar
, Moon Young Kim
  • Corresponding author
  • Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 569, Nonhyon-ro, Gangnam-gu, Seoul 06135, The Republic of Korea
  • Email
  • Search for other articles:
  • degruyter.comGoogle Scholar
and Han Sung HwangORCID iD:



To determine the reproducibility of the mean strain value in various cervical areas and new elastographic parameters for measuring cervical stiffness evaluated by strain elastography using in vivo compression generated by internal organ movement.


A prospective observational study (140 singleton pregnant women; 15–33 weeks of gestation) was performed at two tertiary centers. Cervical strain was evaluated using E-cervix™ elastography. The mean strain levels of various cervical areas [internal os (IOS), external os (EOS) and endocervical area] and several new parameters [i.e. the ratio of the strain level of IOS and EOS, elasticity contrast index (ECI), and hardness ratio] were assessed twice by two independent examiners. The inter-observer and intra-observer variances were calculated using the intraclass correlation coefficient (ICC) with a 95% confidence interval (CI). Bland-Altman (B-A) analysis was also performed.


The median gestational age was 24.0 weeks, and the mean cervical length (CL) was 3.8 cm. The intra-observer and inter-observer ICCs of the mean strain levels of the specified cervical area and new elastographic parameters were statistically significant (P < 0.001, all); the intra-observer ICC was 0.639–0.725, and the inter-observer ICC was 0.538–0.718.


The reproducibility of elastographic parameter measurements using in vivo compression is improvable.

  • 1.

    Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet 2012;379:2162–72.

  • 2.

    Heath VC, Southall TR, Souka AP, Elisseou A, Nicolaides KH. Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery. Ultrasound Obstet Gynecol 1998;12:312–7.

  • 3.

    Hibbard JU, Tart M, Moawad AH. Cervical length at 16–22 weeks’ gestation and risk for preterm delivery. Obstet Gynecol 2000;96:972–8.

  • 4.

    Domin CM, Smith EJ, Terplan M. Transvaginal ultrasonographic measurement of cervical length as a predictor of preterm birth: a systematic review with meta-analysis. Ultrasound Q 2010;26:241–8.

  • 5.

    Esplin MS, Elovitz MA, Iams JD, Parker CB, Wapner RJ, Grobman WA, et al. Predictive accuracy of serial transvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. J Am Med Assoc 2017;317:1047–56.

  • 6.

    Grobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med 2018;379:513–23.

  • 7.

    Kim HI, Choo SP, Han SW, Kim EH. Benefits and risks of induction of labor at 39 or more weeks in uncomplicated nulliparous women: a retrospective, observational study. Obstet Gynecol Sci 2019;62:19–26.

  • 8.

    Magro-Malosso ER, Saccone G, Chen M, Navathe R, Di Tommaso M, Berghella V. Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomized controlled trials. Br J Obstet Gynaecol 2017;124:414–21.

  • 9.

    Baños N, Migliorelli F, Posadas E, Ferreri J, Palacio M. Definition of failed induction of labor and its predictive factors: two unsolved issues of an everyday clinical situation. Fetal Diagn Ther 2015;38:161–9.

  • 10.

    Goddi A, Bonardi M, Alessi S. Breast elastography: a literature review. J Ultrasound 2012;15:192–8.

  • 11.

    Lyshchik A, Higashi T, Asato R, Tanaka S, Ito J, Mai JJ, et al. Thyroid gland tumor diagnosis at US elastography. Radiology 2005;237:202–11.

  • 12.

    Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol 2003;29:1705–13.

  • 13.

    Swiatkowska-Freund M, Preis K. Elastography of the uterine cervix: implications for success of induction of labor. Ultrasound Obstet Gynecol 2011;38:52–6.

  • 14.

    Hwang HS, Sohn IS, Kwon HS. Imaging analysis of cervical elastography for prediction of successful induction of labor at term. J Ultrasound Med 2013;32:937–46.

  • 15.

    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.

  • 16.

    Hernandez-Andrade E, Romero R, Korzeniewski SJ, Ahn H, Aurioles-Garibay A, Garcia M, et al. Cervical strain determined by ultrasound elastography and its association with spontaneous preterm delivery. J Perinat Med 2014;42:159–69.

  • 17.

    Kagan KO, Sonek J. How to measure cervical length. Ultrasound Obstet Gynecol 2015;45:358–62.

  • 18.

    Luo S, Lim DJ, Kim Y. Objective ultrasound elastography scoring of thyroid nodules using spatiotemporal strain information. Med Phys 2012;39:1182–9.

  • 19.

    Bartko JJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep 1966;19:3–11.

  • 20.

    Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420–28.

  • 21.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74.

  • 22.

    Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10.

  • 23.

    Hernandez-Andrade E, Hassan SS, Ahn H, Korzeniewski SJ, Yeo L, Chaiworapongsa T, et al. Evaluation of cervical stiffness during pregnancy using semiquantitative ultrasound elastography. Ultrasound Obstet Gynecol 2013;41:152–61.

  • 24.

    Molina FS, Gómez LF, Florido J, Padilla MC, Nicolaides KH. Quantification of cervical elastography: a reproducibility study. Ultrasound Obstet Gynecol 2012;39:685–9.

  • 25.

    Fruscalzo A, Londero AP, Fröhlich C, Möllmann U, Schmitz R. Quantitative elastography for cervical stiffness assessment during pregnancy. BioMed Res Int 2014;2014:826535.

  • 26.

    Hee L, Sandager P, Petersen O, Uldbjerg N. Quantitative sonoelastography of the uterine cervix by interposition of a synthetic reference material. Acta Obstet Gynecol Scand 2013;92:1244–9.

  • 27.

    Swiatkowska-Freund M, Pankrac Z, Preis K. Intra- and inter-observer variability of evaluation of uterine cervix elastography images during pregnancy. Ginekol Pol 2014;85:360–4.

  • 28.

    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 2019. doi: 10.1007/s00404-019-05377-5 [Epub ahead of print].

  • 29.

    Park HS, Kwon H, Kwak DW, Kim MY, Seol HJ, Hong JS, 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.

Purchase article
Get instant unlimited access to the article.
Price including VAT
Log in
Already have access? Please log in.

Journal + Issues

The Journal of Perinatal Medicine is a truly international forum covering the entire field of perinatal medicine. It is an essential news source for all those obstetricians, neonatologists, perinatologists and allied health professionals who wish to keep abreast of progress in perinatal and related research.