Cervical elastography during pregnancy: a critical review of current approaches with a focus on controversies and limitations.

In normal pregnancy, the cervix functions as a protective mechanical barrier that must remain tight and closed. Premature remodeling and consecutive shortening occur in many cases of spontaneous preterm birth. Although the complex underlying physiology of normal and abnormal cervical remodeling is not fully understood, it is clear that cervical softening occurs prior to delivery, and inappropriate timing seems to be associated with preterm delivery. Also, degree of cervical softness is a component of the Bishop score currently used clinically to predict successful induction of labor. Therefore, the assessment of changes in cervical stiffness with ultrasound elastography techniques might be useful in the prediction of preterm delivery or successful induction of labor. Two different approaches for cervical elastography for quantitative determination of the physical properties of the pregnant cervix have been developed: strain elastography and shear wave elastography. Recently, several feasibility studies showed the reliability of these cervical elastography techniques for the prediction of preterm delivery and successful labor induction. In this review, we contrast strain elastography, which determines only relative values of tissue stiffness because the applied transducer pressure is unknown, with shear wave elastography, which provides, in principle at least, a more objective description of tissue softness. While more promising preliminary results involving these approaches to assessing cervical softness have been recently published, current limitations in technical implementation need to be addressed before elastography techniques will become clinically useful. We discuss these limitations and present challenges for future studies and equipment development.