Middle East Fertility Society Journal (2010) 15, 188193

Middle East Fertility Society

Middle East Fertility Society Journal

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ORIGINAL ARTICLE

Ultrasonographic evaluation of lower uterine

segment thickness in pregnant women with previous
cesarean section
Abdel Baset F. Mohammed *, Diaa A. Al-Moghazi, Mamdouh T. Hamdy,
Enas M. Mohammed

Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Egypt

Received 13 September 2009; accepted 14 October 2009

Available online 1 September 2010

KEYWORDS Abstract Objective: To evaluate the accuracy of prenatal sonography (U/S) in determining the
Pregnancy; lower uterine segment (LUS) thickness in women with previous cesarean section (CS) and to assess
Previous CS; its usefulness in predicting the risk of uterine rupture during a trial of vaginal birth.
VBAC; Design: Prospective controlled study.
Ultrasound Setting: Suzan Mubarak University Hospital.
Subjects: One hundred and fty pregnant women with singleton pregnancies, with the gestational
age between 37 and 40 weeks were recruited for the study during the period from October 2007 to
June 2008. The recruited patients were allocated into three equal groups. Group I included those
with previous one low transverse CS and with the history of successful VBAC. Group II included
those without the history of successful VBAC. Group III included those without the previous his-
tory of CS (control group).
Interventions: The recruited patients were subjected to clinical and U/S evaluations. The LUS
thickness was evaluated by both transabdominal (TA) and transvaginal (TV) U/S. Women were
categorized for the mode of delivery into either trial of VBAC or elective repeated CS (ERCS).
All the intraoperative ndings were correlated with U/S ndings.
Main outcome measures: Accuracy of US in predicting uterine dehiscence.

* Corresponding author. Tel.: +20 9745458229; fax: +20

9744393910.
E-mail address: abdu163@yahoo.com (A.B.F. Mohammed).

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Ultrasonographic evaluation of lower uterine segment thickness in pregnant women 189

Results: Mean LUS thickness was lower among the study groups than in the control group. The
present study reported 14 (28%) cases of dehiscent scar. Mean LUS thickness was signicantly
lower among the dehiscence groups (1.7 0.7 mm) than in the non-dehiscence groups
(2.6 0.8 mm) (P 6 0.01). At a cutoff value of 2.5 mm, the sensitivity, specicity, and positive
and negative predictive values were 90.9%, 84%, 71.4%, and 95.5%, respectively, using (TA) U/
S and 81.8%, 84%, 69.2%, and 91.3%, respectively, using (TV) U/S. At LUS thickness
62.5 mm, there was a higher risk for dehiscence than those with a thickness of more than 2.5 mm.
Conclusions: If the thickness of the LUS is more than 2.5 mm, the possibility of dehiscence during
the subsequent trials of labor is very small and a safe vaginal delivery can be achieved. Further large
studies are recommended.
 2010 Middle East Fertility Society. Production and Hosting by Elsevier B.V. All rights reserved.

1. Introduction of successful VBAC. Group III (N = 50) included those with-

Vaginal birth after cesarean section (VBAC) has become an
integral part of modern obstetrics with more than 100,000
VBACs achieved each year nationwide (1). Despite this, it re-
mains a controversial issue. Although it has been reported as
safe and has contributed to a reduced cesarean delivery (CS)
rate (24), VBAC is associated with a risk of uterine rupture
(5). Because the maternal and fetal consequences of uterine
rupture can be serious and potentially life threatening (6,7),
the proper selection of patients would be an important prere-
quisite. It is generally considered that, among carefully selected
patients who have full participation in decision making, most
women with one previous transverse LSCS are suitable candi-
dates for VBAC and should be offered a trial of labor (8,9).
Although the efcacy and safety of VBAC have been shown
(2,4), to our knowledge, there are no reliable methods to pre-
dict the risks of uterine rupture in this group of patients. Stud-
ies have shown that the risk of uterine rupture in the presence
of a defective scar is related directly to the degree of thinning
of the LUS (10,11).
Sonographic examination of the LUS has been used to
diagnose a uterine defect and to determine the degree of
LUS thinning in women with previous CS (12,13). Previous
studies have demonstrated that the LUS thickness measured
sonographically has a high negative predictive value for uterine
rupture, suggesting that a normal LUS thickness predicts a
safe trial of VBAC. However, the clinical application of LUS
measurement in the management of VBAC remains controver-
sial (14). This prospective controlled trial was conducted to
evaluate the accuracy of prenatal sonography in determining
the LUS thickness in women with previous CS and to assess
its clinical application in predicting the risk of uterine rupture
during a trial of vaginal birth.
out previous history of CS (control group). All the patients
were selected from the attendees of the outpatient clinic or
those admitted to the inpatient department. Thorough coun-
seling was given and a written informed consent was obtained
from each patient prior to participation in the study. Those
with previous 2 or more CS, low lying placenta, premature
rupture of fetal membranes, multiple pregnancies, previous
uterine rupture or other uterine scars and those in an active
phase of labor were excluded from the study.
The recruited patients were subjected to detailed history
taking, clinical examination and routine US examination.
Then, the LUS thickness was evaluated by both transabdomi-
nal (TA) and transvaginal (TV) U/S. Measurement was done
with a full bladder and in the absence of any uterine contrac-
tion which may distort the LUS. In TA U/S, the LUS was
scanned in the sagittal section under magnication to localize
the thinnest area. Two to three measurements were taken, and
the lowest value was taken as the LUS thickness. Scanning was
also performed from the lateral aspect of the LUS to detect
any asymptomatic dehiscence, ballooning, funneling, or wedge
defect as described by Michaels et al. (15) (any abnormal bulg-
ing of the outer layer associated with fetal movement or
changes in amniotic uid pressure against the urinary bladder
base). The measurement was taken with the cursors at the uri-
nary bladder wallmyometrium interface and the myome-
trium/chorioamniotic membraneamniotic uid interface
(Fig. 1). In TV U/S, the thickness of the LUS was measured

2. Materials and methods

This prospective controlled study was conducted in the depart-

ment of Obstetrics and Gynecology, Faculty of Medicine,
Minia University (Suzan Mubarak University Hospital) during
the period from October 2007 to June 2008 after being ap-
proved by the department Ethical Committee. One hundred
and fty pregnant women with singleton pregnancies, with
the gestational age between 37 and 40 weeks were recruited
in the study. The recruited patients were allocated into three
equal groups. Group I (N = 50) included those with previous Figure 1 TV U/S showing the LUS and bladder full. Open
one low transverse CS and with the history of successful arrow indicates the uterine wall; solid arrow indicates the bladder
VBAC. Group II (N = 50) included those without the history wall.
190 A.B.F. Mohammed et al.

after identication of the bladder in the longitudinal plane of

the cervical canal with the vaginal probe placed in the poster-
ior fornix. All examinations were performed by the same
sonographer on Medison US machine with 3.75 convex array
transducer and 7 MHz vaginal probe. Sonographic ndings
were prescribed as follows: (1) Normal symmetrical or asym-
metrical thickness of more than 2 mm (Fig. 2). (2) Thin sym-
metrical or asymmetrical thickness of less than 2 mm
(Fig. 3). (3) Abnormal thinning, loss of US denition of myo-
metrium and loss of continuity. (4) Defect, some defect of the
myometrium present in the LUS (Fig. 4).
According to the quality of the healed scar, pregnant wo-
men were categorized for the mode of delivery into either a
trial for VBAC (if LUS is >2 mm and in the absence of other
indications for CS) or an elective repeated cesarean section
(ERCS) (if LUS thickness is <2 mm, the presence of balloon-
ing, funneling, or defects in the LUS, the presence of other Figure 4 Funneling of the LUS as seen by transvaginal
indications for CS or the patient refusal of VBAC). Patients gi- ultrasound. The LUS at the funneling site is 2.3 mm.
ven a trial of VBAC developed a spontaneous onset of labor.
Augmentation by oxytocin was resorted to in certain cases
by half strength protocol. No patients were induced. After a were continuously monitored, and were taken up for an emer-
vaginal delivery, the uterine scar was not routinely explored gency CS for any intrapartum adverse events. Uterine dehis-
unless there was an abnormal symptom such as excessive cence was diagnosed when the digital examination palpated
bleeding or pain. The women who underwent a trial of VBAC the serosa without an intervening muscular layer. When this
occurred, digital contact with the mucosa was conrmed with
the use of TA U/S.
During repeat CS, the surgeon was asked to comment on
the appearance of the LUS under the following categories as
described by Qureshi et al. (16). Class I (well-developed
LUS), Class II (thin LUS, content not visible), Class III (trans-
lucent LUS, content visible), and Class IV (well-circumscribed
defect, either dehiscence or rupture present in the LUS). Clas-
ses I and II are considered non-dehiscent, while Classes III and
IV are considered dehiscent. Neonatal assessment was done by
a neonatologist attending each delivery.

2.1. Statistical analysis

Data are expressed as the mean standard deviation

(Mean SD) or as the number and percent (N%). The un-
paired Student t-test and chi-square (v2) were used to compare
between groups. P value <0.05 was considered signicant.
Figure 2 Thick LUS (5.5 mm) by TA U/S. Correlation coefcient test was used to evaluate the relation-
ship between both the intraoperative ndings and intrapartum
events and the US ndings. Receiver operating characteristic
curve ROC curve was used to detect the critical thickness
of the LUS measured by the US ndings above which safe vag-
inal delivery can be attempted. Statistical analysis was per-
formed on the SPSS Advanced Statistical Software Version
13 (SPSS Inc., Chicago, USA).

3. Results

The patient characteristics of the two groups are reported in

Table 1. Mean LUS thickness was signicantly lower among
the study group (P = 0.0001). The most frequent indication
of previous CS in Group I was fetal distress [20 (40%)] and
in group II, failure of progress [11 (22%)]. It is also noted that
40% of previous CS in the study group was done in our hos-
pital while 60% had it done at another places. Mode of
delivery of the pregnant women included in the study group
Figure 3 Thin LUS (1.3 mm) by TV U/S. in the current pregnancy is reported in Table 2. There was a
Ultrasonographic evaluation of lower uterine segment thickness in pregnant women 191

Table 1 Clinical characteristics of patients in different groups.

Variable Study group Control group (N = 50) P-Value
Group I (N = 50) Group II (N = 50)
Age (Mean SD) 26.5 5.1 28.7 4.2 27.3 4.8 0.06
Parity 2.6 0.8 2.7 0.9 3 1.1 0.09
Gestational age (Mean SD) 37.7 0.7 37.7 0.6 37.8 0.5 0.7
Interdelivery interval (Mean SD) 3.09 1.3 3.05 1.4 2.6 0.8 0.09
LUS thickness
TA U/S 3.2 0.4 3.7 0.5 3.9 0.5 0.0001
TV U/S 2.6 0.4 3.1 0.5 3.7 0.4 0.0001
SD, standard deviation; N, number; P, probability; LUS, lower uterine segment; TA U/S, transabdominal ultrasound; TV U/S, transvaginal
ultrasound.

The present study reported that the presence of scar dehis-

Table 2 The mode of delivery of patients in the study group in
the current pregnancy.
Study group ERCS Emergency CS Successful VBAC
Total (N = 100) 10 (10%) 22 (22%) 68 (68%)
Group I (N = 50) 3 (6%) 5 (10%) 42 (84%)
Group II (N = 50) 7 (14%) 17 (34%) 26 (52%)
ERCS, elective repeated cesarean section; N, number; VBAC,
vaginal birth after cesarean section.
signicant positive correlation between TA and TV U/S in the
measurement of LUS thickness in each of the study and the
control groups (r = 0.75, P = 0.0001; r = 0.86, P = 0.0001,
respectively).
The present study reported 14 (28%) cases of dehiscent
scar. All the cases lie in Group II. Four cases of dehiscence
underwent ERCS as they had LUS less than 2 mm which re-
ects the poor quality of scar healing. Six cases underwent
an emergency CS indicated by persistent fetal bradycardia
not responding to the corrective measures. One case underwent
ERCS due to the presence of abnormal funneling of the LUS
detected by TV U/S. One case underwent ERCS as she refused
VBAC. One case underwent ERCS due to the prolonged pre-
mature rupture of fetal membranes more than 24 h. One case
delivered vaginally with good fetal outcome. The patient devel-
oped a mild attack of primary postpartum hemorrhage (PPH).
After exclusion of other causes of PPH, palpation of the scar
revealed a small defect at the left angle about 2 2 cm, which
managed conservatively.
cence was not related to maternal age, parity, gestational age
at delivery, birth weight, Apgar score of less than 7 at 5 min,
and the presence of pain and/or tenderness at the site of the
scar (P > 0.05 for each). It is also shown that the risk of scar
dehiscence was higher with short period of interdelivery inter-
val (P is 0.003), higher in pregnant women whose previous CS
was indicated by CPD (P = 0.002), and in cases who had their
previous CS outside Minia University Hospital (64.2%)
(P = 0.2). No correlation was found between the augmenta-
tion of labor and the occurrence of uterine dehiscence. Ultr-
asonographic measurement of LUS thickness was compared
between the dehiscent and non-dehiscent groups. In the group
of dehiscence, the thickness was 1.7 0.7 mm. in the group
without dehiscence, it was 2.6 0.8 mm. the difference was
signicant (P 6 0.01). The relation between the dehiscence of
the scar and thickness of the LUS is reported in Table 3.
As shown in Table 4, at a cutoff value of 2.5 mm, the sen-
sitivity, specicity, and positive (PPV) and negative (NPV) pre-
dictive values were 90.9%, 84%, 71.4%, and 95.5%,
respectively, using TA US, and 81.8%, 84%, 69.2%, and
91.3%, respectively, using TV US. Fig. 5 shows the receiver
operator characteristic curve ROC curve illustrating sensi-
tivity and 1-specicity for different cutoff levels of LUS thick-
ness. The mean of the area under ROC curve for LUS
thickness measured by TV U/S was higher (0.94 0.03) than
that for LUS thickness measured by TA U/S (0.85 0.08). As
reported in Table 5, at LUS thickness 62.5 mm, there was a
higher risk for dehiscence than those with a thickness more
than 2.5 mm.

Table 3 The relation between dehiscence of the scar and thickness of the LUS.
Integrity of the scar Thickness of LUS in mm P
<2 23 >3
By TA U/S
Intact 2 (28.6%) 12 (60%) 72 (98.6%) 0.0001
Dehiscent 5 (71.4%) 8 (40%) 1 (1.4%)
Total 7 (100%) 20 (100%) 73 (100%)
By TV U/S
Intact 1 (20%) 55 (87.3%) 30 (93.8%) 0.0001
Dehiscent 4 (80%) 8 (12.4%) 2 (6.2%)
Total 5 (100%) 63 (100%) 32 (100%)
P, probability; LUS, lower uterine segment; TA U/S, transabdominal ultrasound; TV U/S, transvaginal ultrasound.
 192 A.B.F. Mohammed et al.

Table 4 Sensitivity, specicity, and positive and negative predictive values at corresponding LUS thicknesses using TA and TV U/S.
LUS thickness Sensitivity Specicity PPV NPV
TAUS TVUS TAUS TVUS TAUS TVUS TAUS TVUS
62 45.5 63.6 100 100 100 100 86.2 86.2
62.5 90.9 81.8 84 84 71.4 69.2 95.5 91.3
63 90.9 90.9 68 72 55.6 58.8 94.4 94.7
63.5 90.9 90.9 52 56 45.5 47.6 92.9 93.3
64 90.9 90.9 24 24 34.5 34.5 85.1 85.7
64.5 90.9 90.9 16 12 32.3 31.3 80 75
65 90.9 100 8 8 30.3 32.4 100 100
LUS, lower uterine segment; PPV, positive predictive value; NPV, negative predictive value; TA U/S, transabdominal ultrasound; TV U/S,
transvaginal ultrasound.

ROC Curve study, uterine dehiscence was found at the time of ERCS prior
1.0
to the onset of labor. Other reports have shown that the uter-
ine dehiscence is a high risk condition for uterine rupture (18).
Therefore, measurement of the LUS thickness prior to the on-
0.8 set of labor may have clinical signicance if it can identify the
uterine dehiscence. The tissues adjacent to the uterine scar tend
to be thinner in gravidas with previous CS than in those with-
out CS. Thinning of the LUS is considered to be a result of
Sensitivity

0.6
stretching in a portion of the LUS caused by the gestation it-
self, which does not occur in the scarred tissue. Scarred tissue
0.4
is rigid and does not stretch. Furthermore, during labor, the
descent of the fetal head may stretch the LUS further and
makes the LUS thinner possibly leading to uterine rupture.
Source of the Curve
thicknestransvaginal In a uterus with disturbed healing, the LUS may become extre-
0.2
thicknessonar mely thin during gestation. Thus, the quality and integrity of
the LUS can be evaluated by the LUS thickness (17). The pres-
ent study reported that the prior CS is associated with a sono-
0.0 graphically thinner LUS when compared with those with prior
0.0 0.2 0.4 0.6 0.8 1.0
vaginal delivery. This is in agreement with Cheung et al. (19)
1 - Specificity who reported the same ndings.
Diagonal segments are produced by ties. Most studies have used TA U/S alone (20,21,16), TV U/S
alone (22,11) or both TA and TV U/S (23) in the evaluation
Figure 5 Receiver operator characteristic curve between TA and of LUS thickness. In the present study, the interclass correla-
TV U/S. tion of 0.86 found between TA U/S and TV U/S implies a
strong index of correlation between the two (P = 0.0001).
But, if TV U/S is not available, TA U/S with magnication
Table 5 Relative risk of dehiscence of previous CS scar at can be used. Image resolution, identication of the various lay-
different LUS thicknesses. ers, and ease of measurement are better with TV U/S; but it re-
LUS thickness (mm) Relative risk of dehiscence (%) quires greater expertise.
In the present study, 2.5 mm was considered the critical cut-
TA U/S
off value of the LUS thickness above which safe vaginal deliv-
62.5 92.9
>2.5 7.1
ery can be achieved. This critical cutoff value was derived from
the ROC curve with sensitivity, specicity, PPV, and NPV
TV U/S 90.9%, 84%, 71.4%, and 95.5%, respectively (using TA U/
62.5 85.7 S), and 81.8%, 84%, 69.2%, and 91.3%, respectively (using
>2.5 14.2
TV U/S). Regarding the critical thickness, this study had a
LUS, lower uterine segment; TA U/S, transabdominal ultrasound; high NPV, implying that a thick LUS is generally strong.
TV U/S, transvaginal ultrasound. The reported cutoff in the present study was in agreement with
that reported by Sen et al. (23). However, in the study of
Rozenberg et al. (20), the derived cutoff was 3.5 mm using
TA U/S. They reported a sensitivity of 88%, NPV of 95.3%,
4. Discussion a specicity of 73.2%, and a PPV of 11.8%. Cheung (13) re-
ported that a cutoff thickness of 1.5 mm had a sensitivity of
Uterine dehiscence occurs in 0.44.6% of VBAC cases. It is 88.9%, a specicity of 59.5%, a PPV of 32.0%, and a NPV
known to be asymptomatic and not life threatening. However, of 96.2% in predicting a paper-thin or dehisced LUS. It is
it may exists prior to the onset of labor (17). In the present therefore obvious that the techniques used for measuring the
Ultrasonographic evaluation of lower uterine segment thickness in pregnant women
LUS thickness and identifying uterine defects have not been
consistent among different studies, although some studies seem
to give good results with different measurement techniques
(15,16,24).
There was a positive correlation between intraoperative
grading of the LUS and its thickness by US. This demonstrates
that, the lower the LUS thickness, the higher the risk of scar
dehiscence. The relative risk of dehiscence at the LUS thickness
below or equal to the critical cutoff value 2.5 mm using TA
U/S was 92.9% and it was 7.1% for thicknesses more than
2.5 mm. Using TV U/S, the relative risk of dehiscence at the
LUS thickness below or equal to the critical cutoff value
2.5 mm was 85.7% and it was 14.2% for thicknesses more
than 2.5 mm. This implies that the thicker the LUS thickness
more than 2.5 mm as measured by US, the less likely is the pos-
sibility of dehiscence of LUS as seen in the intraoperative, and
this may encourage obstetricians to offer a trial of labor to wo-
men with a LUS thickness of 2.5 mm or greater. It was found in
this study that the absolute risk of dehiscence was 14%. This is
considered as a high percent but this may be due to the relatively
small sample size, also the study was done at a tertiary medical
centre, so, most of our cases are at high risk with a higher pos-
sibility of complications. However, this study was small; larger
studies on similar lines are needed to verify its ndings.
Although the LUS thickness in all women with Grade IV
intraoperative was 2 mm or less, a total of 2 patients
(28.6%) using TA U/S and 1 patient (20%) using TV U/S
delivered vaginally at a thickness of less than 2 mm, without
any adverse fetomaternal outcome. This is consistent with
the study conducted by Sen et al. (23) who found that,
although the derived cutoff value was 2.5 mm, a total of 8 pa-
tients (24.2%) using TA U/S and 5 (15.1%) using TV U/S
delivered vaginally at a thickness of less than 2.5 mm, without
any adverse fetomaternal outcome.
However, Cheung (14) reported that the clinical application
of the LUS measurement in the management of VBAC re-
mains controversial. Clinical experience with the use of the
LUS measurement in predicting uterine rupture and managing
VBAC is limited. Having a national registry to record data and
review all cases of uterine rupture would accelerate the accu-
mulation of experience on this subject. The present study sug-
gests that sonographic LUS evaluation is potentially capable
of identifying those patients with a thin or defective LUS,
which could carry a higher risk of subsequent rupture when
a trial of VBAC is attempted. If the thickness of the LUS is
more than 2.5 mm, the possibility of dehiscence during the
subsequent trials of labor is very small and a safe vaginal deliv-
ery can be achieved.
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