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

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 I ² 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.