Ultrasound Obstet Gynecol 2013; 41: 556562

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.12334

Changes in Cesarean section scar dimensions during

pregnancy: a prospective longitudinal study
O. NAJI*, A. DAEMEN, A. SMITH*, Y. ABDALLAH*, S. SASO, C. STALDER*,
A. SAYASNEH*, A. McINDOE, S. GHAEM-MAGHAMI, D. TIMMERMAN and
T. BOURNE*
*Obstetrics and Gynecology Unit, Queen Charlottes and Chelsea Hospital, Imperial College London, London, UK; Institute of
Reproductive and Developmental Biology, Imperial College London, London, UK; Department of Development and Regeneration,
University Hospitals KU Leuven, Leuven, Belgium; The Wellington Hospital, London, UK

K E Y W O R D S: Cesarean section scar; transvaginal ultrasonography; VBAC

ABSTRACT
Objectives To describe changes in Cesarean section (CS)
scars longitudinally throughout pregnancy, and to relate
initial scar measurements, demographic variables and
obstetric variables to subsequent changes in scar features
and to final pregnancy outcome.
Methods In this prospective observational study we used
transvaginal sonography (TVS) to examine the CS scar
of 320 consecutive pregnant women at 1113, 1921
and 3234 weeks gestation. For scars visible on TVS,
the hypoechoic part was measured in three dimensions
and the residual myometrial thickness (RMT) was also
measured. Analyses were carried out using one-way
repeated measures ANOVA and mixed modeling. The
incidence of subsequent scar rupture was recorded.
Results The CS scar was visible in 284/320 cases (89%).
Concerning length and depth of the hypoechoic part of
the scar and RMT, the larger the initial scar measurement,
the larger the decrease observed during pregnancy. For
the hypoechoic part of the scar, the width increased
on average by 1.8 mm per trimester, while the depth
and length decreased by 1.8 and 1.9 mm, respectively
(false discovery rate P < 0.0001). Mean RMT in the first
trimester was 5.2 mm and on average decreased by 1.1 mm
per trimester. Two cases (0.62%) of uterine scar rupture
were confirmed following a trial of vaginal delivery; these
had a mean RMT of 0.5 mm at second scan and an average
decrease of 2.6 mm over the course of pregnancy.
Conclusion This study establishes reference data and
confirms that the dimensions of CS scars change
throughout pregnancy. Scar rupture was associated with
a smaller RMT and greater decrease in RMT during

pregnancy. There is the potential to test absolute values

and observed changes in CS scar measurements as
predictors of uterine scar rupture and outcome in trials of
vaginal birth after Cesarean section. Copyright 2012
ISUOG. Published by John Wiley & Sons Ltd.

INTRODUCTION
A number of studies have used ultrasound imaging to
describe Cesarean section (CS) scars1 8 ; however, most
have been carried out on non-pregnant women and
findings are thus difficult to interpret in relation to the
pregnant state. The appearance of CS scars on ultrasound
examination may be clinically relevant, but there is limited
evidence relating scar appearance to uterine function in a
future pregnancy. A recent study by Vikhareva Osser et al.
suggested a possible relationship between the appearance
of a CS scar in non-pregnant women and scar performance
in a subsequent pregnancy. However, the number of cases
included in the study was too small to draw definitive
conclusions6 .
It is not known whether a CS scar described as deficient
on ultrasound is associated with increased risk of failed
vaginal birth or uterine rupture in labor. The terms scar
deficiency or presence of a niche refer to a hypoechoic
area of varying size within the uterine wall. A CS scar is
usually made up of two components: the hypoechoic part
(or apparent defect) and scar tissue contained within the
residual myometrium. The latter part of the scar can be
usefully expressed as the residual myometrial thickness
(RMT).
Different grades of apparent deficiency with regard
to size of the hypoechoic area relative to RMT have
been reported according to the subjective impression of

Correspondence to: Dr S. Ghaem-Maghami, Institute of Development and Reproductive Biology, Imperial College London, Hammersmith
Campus, Du Cane Road, London W12 0HS, UK (e-mail: s.ghaem-maghami@imperial.ac.uk)
Accepted: 2 October 2012

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

ORIGINAL PAPER

Cesarean section scars during pregnancy

the operator. However, a more objective quantitative
approach is desirable if CS scar assessment is to
be reproducible. We have previously proposed a
standardized approach for assessment of the hypoechoic
portion of the scar based on objective measurements in
addition to measurement of RMT9 .
Various methods have been developed with the aim of
correlating measurements of the lower uterine segment
(LUS) during pregnancy with risk of uterine rupture
or dehiscence10 15 . In some studies, the thickness of
the entire LUS was measured using transabdominal
sonography, while in others only the muscular layer was
measured using TVS. Measurement of the muscular layer
of the LUS appears to be clinically important. Jastrow
et al. conducted a systematic review on this topic and
concluded that there is a strong association between
smaller LUS measurements in pregnancy and risk of
uterine scar complications, proposing that LUS thickness
as evaluated by sonography might serve as a predictor
of uterine rupture16 . However, no cut-off values have
been developed and tested, underlining the need for more
standardized measurement techniques and nomenclature.
The ability to predict likely success of a trial of labor
would be clinically useful15 . A number of groups have
attempted to select patients more likely to undergo
successful vaginal birth after Cesarean section (VBAC)
according to demographic variables as well as findings on
physical examination at the time of admission for delivery.
Growing evidence suggests that complete healing of the
previous CS scar and myometrial thickness of the LUS are
important factors in achieving an uneventful pregnancy
outcome17 .
In this prospective study we describe changes in
dimensions of the hypoechoic part and RMT of CS scars
that occur throughout the course of pregnancy. We also
investigated some of the factors that might be associated
with larger scars using previously published methods of
scar measurement.

557

routine first-trimester screening, anomaly screening and

growth assessment scans when possible. At the first scan
visit, demographic data were recorded and an obstetric
and medical history was obtained. This included the
number of previous CSs and whether any had been
complicated by postpartum infection. The operators
performing scans were blind to this clinical information.
The delineation and measurements of the CS scar
using ultrasound were carried out according to methods
reported previously9 (Figures 1 and 2). LUS was assessed
using ultrasonography in real-time to identify the area
likely to contain the CS scar. Two components of CS scars
were assessed: the hypoechoic part or apparent defect
and the scar contained in any residual myometrium, which
for measurement purposes is expressed as RMT. As a
relationship between scar appearance and function has
not been shown, we have chosen to avoid using the term
deficiency or defect as a morphological descriptor.
When the CS scar was visible, three measurements
were taken in the sagittal plane, the width and depth of
the hypoechoic part and RMT, while the length of the
hypoechoic part was measured in the transverse plane.
This method was applied at each scan and data were
recorded prospectively on an Excel spreadsheet.

Statistical analysis
The median and 25th 75th percentile for width, depth
and length of the hypoechoic part of the CS scar
and RMT were calculated for each trimester. These
scar characteristics were compared over the three
trimesters using one-way repeated measures ANOVA.
The corresponding P-values were corrected for multiple
testing with the false discovery rate (FDR) approach of
Benjamini and Hochberg18 .
An initial graphic exploration suggested approximately
linear trends for scar dimensions over time. In order to
draw conclusions from our sample about typical scar

METHODS
The study was conducted at the ultrasound department of
a London university teaching hospital and was approved
by the local research and ethics committee. Informed
consent was obtained from all women. Between June 2010
and July 2011, 389 non-selected consecutive pregnant
women were enrolled. We included women with singleton
gestations who had undergone at least one previous lowtransverse CS. Women with multiple gestations (n = 19)
and those with a history of classical CS (n = 11) were
excluded from the study. Thirteen cases had a midtrimester miscarriage, 17 cases withdrew from the study
after subsequent scans and nine cases were lost to followup. The final study cohort consisted of 320 women
who were examined using a Voluson E8 Expert (GE
Healthcare Ultrasound, Milwaukee, WI, USA) ultrasound
system equipped with a 59-MHz transvaginal probe.
All participating women underwent TVS at 1113,
1921 and 3234 weeks gestation, coinciding with

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

E
D

Figure 1 Sagittal ultrasound image showing anatomical location of

features measured to quantify size of component parts of a
Cesarean section scar using transvaginal sonography in first
trimester of pregnancy. A, width of hypoechoic part; B, depth of
hypoechoic part; C, residual myometrial thickness; D, uterovesical
fold; E, internal cervical os.

Ultrasound Obstet Gynecol 2013; 41: 556562.

Naji et al.

558
(a)
D
B
A

(b)

and underwent a repeat CS procedure as initially planned.

Women in the group with visible CS scar with a history
of one previous CS (n = 131) were counseled and offered
a trial of VBAC at 38 weeks gestation, of which 10
women required prelabor CS at < 38 weeks gestation for
various clinical reasons, 74 women (61%) had successful
trials of labor and 47 women required intrapartum
emergency CS because of failed trials of labor. In the
cohort of women selected for trial of VBAC there were
two (0.62%) cases of scar rupture and five (1.5%) cases
of dehiscence confirmed at repeat CS. The breakdown
of patients for both visible and non-visible scar groups is
demonstrated in Figure 3. Demographic data and obstetric
variables are shown in Table 1.
Non-visible scars (n = 36) at the 12-week scan remained
non-visible on subsequent scans. Scar visibility was related
to position of the uterus, with 81% (n = 29) of non-visible
scars found among the 42 women in whom the uterus was
retroverted. Within the group with visible scars, there was
one woman among the 153 who had undergone more than
one previous CS in whom more than one scar was visible.
In this case measurements of the larger scar were taken.

Change in scar size during pregnancy

Figure 2 Schematic diagram showing Cesarean scar dimensions in
sagittal (a) and transverse (b) planes. A, width of hypoechoic part
of scar (apparent defect) in sagittal plane; B, depth of hypoechoic
part of scar (apparent defect) in sagittal plane; C, length of
hypoechoic part of scar (apparent defect) in transverse plane;
D, residual myometrial thickness in sagittal plane. Reproduced
from Naji et al.9 with permission.

characteristic patterns in the population as a whole, we

fitted mixed models per scar characteristic. Each mixed
model contained two fixed-effects parameters (average
intercept and slope of the scar characteristic against time)
and two correlated random effects (deviations in intercept
and slope among pregnancies). To assess the association of
change in scar characteristics with demographic variables
and obstetric history, interaction terms between these
variables and time were added to the mixed models, with
use of a likelihood ratio test to compare fitted models
with and without the interaction term in each case. All
analyses were performed with R for statistical computing
(www.r-project.org).

RESULTS
A total of 320 women were included in the study. The CS
scar was visible in 284/320 cases (89%). When the scar
was deemed visible at the 12-week scan, it continued to
be visible in 100% of cases at 20 weeks and in 272/284
cases (96%) at 34 weeks. In the group with a visible CS
scar (n = 284), 153 women had a history of more than
one previous CS and therefore were assigned to undergo
elective repeat CS at 39 weeks gestation. Of these,
17 women developed premature uterine contractions
at < 39 weeks gestation, resulting in semi-elective CS,
and 136 women progressed beyond 39 weeks gestation

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

Mixed modeling of scar changes over time showed an

average increase of 1.8 (95% CI, 1.71.9) mm in the
width of the hypoechoic part of the scar per trimester.
Depth and length of the hypoechoic part decreased over
time, with average decreases of 1.8 (95% CI, 1.71.9) mm
and 1.9 (95% CI, 1.82.0) mm per trimester, respectively.
RMT decreased by an average of 1.1 (95% CI, 1.01.2)
mm per trimester. Changes in scar dimensions are illustrated in Figure 4 and Table 2. In the two cases of reported
scar rupture, the decrease in RMT between first and second trimesters was 2.7 and 2.5 mm, respectively. Mean
RMT in these cases was 0.5 mm at the second trimester
scan, in comparison to 3.6 mm for the other cases.

Relationship between initial scar size and change

during pregnancy
For the modeling of scar changes over time, random
effects representing variation in the intercept and slope of
the dimensions vs time relationship were considered to be
dependent because the initial scar size may be correlated
with subsequent change in size throughout pregnancy.
We found that the larger the initial dimensions of the
scar, the more the scar decreased in size between all three
trimesters of pregnancy. This association held for both
depth and length of the hypoechoic segment of the scar
(correlation coefficients for random effects intercept and
slope = 0.887 and 0.904 for scar depth and length,
respectively) and RMT (correlation coefficient, 0.720).

Influence of demographic variables on change in scar

size
Throughout pregnancy, there was a trend towards
enhanced increase in width and enhanced decrease in

Ultrasound Obstet Gynecol 2013; 41: 556562.

Cesarean section scars during pregnancy

559
Study population
(n = 320)

Visible scars
(n = 284)

2 previous CS:
Planned CS at 39 weeks
(n = 153)

ERCD
(n = 136)

Non-visible scars
(n = 36)

1 previous CS:
Planned VBAC at 38 weeks
(n = 131)

EmRCD < 38 weeks

(n = 10)

Semi-elective CS < 39 weeks

(Premature uterine contractions)
(n = 3)

Successful VBAC 38 weeks

(n = 74)

1 previous CS:
Planned VBAC at 38 weeks
(n = 22)
EmRCD < 38 weeks
(n = 2)

ERCD
(n = 11)

Failed VBAC
EmRCD > 38 weeks
(n = 47)
Semi-elective CS < 39 weeks
(Premature uterine contractions)
(n = 17)

2 previous CS:
Planned CS at 39 weeks
(n = 14)

Failed VBAC
EmRCD > 38 weeks
(n = 2)
Successful VBAC 38 weeks
(n = 18)

Figure 3 Outcomes of the study population. CS, Cesarean section; EmRCD, emergency repeat Cesarean delivery; ERCD, elective repeat
Cesarean delivery; VBAC, vaginal birth after Cesarean section.
Table 1 Demographics and obstetric history of the study
population (n = 284)

11
10

Characteristic

Median (IQR) or n (%)

33 (2936)
26 (2431)
12 (4.2)
12 (4.2)
24 (8.4)
67 (23.6)
193 (68.0)

Scar dimension (mm)

Age (years)
BMI (kg/m2 )
History of diabetes mellitus
Chronic steroid use
Smoking status
Smoker
Ex-smoker
Non-smoker
Obstetric history
1 previous CS
2 previous CSs
3 previous CSs
Previous VBAC
Previous postpartum infection

8
7
6
5
4

207 (72.9)
72 (25.3)
5 (1.8)
35 (12.3)
33 (12.3)

BMI, body mass index; CS, Cesarean section; IQR, interquartile

range; VBAC, vaginal birth after Cesarean section.

length of the hypoechoic part of the scar with increasing

maternal age (with a better model fit when including
an interaction term between maternal age and trimester
of scan as compared to the initial mixed effects models
with only trimester as an independent variable; FDR
P-values of the likelihood ratio test = 0.11; Table 3).
Ethnicity, body mass index and history of diabetes
mellitus were not significantly associated with a change

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

3
2
First

Second
Trimester

Third

Figure 4 Mean scar dimensions according to trimester, relating to

the fitted fixed effects from mixed effects modeling. , Residual
myometrial thickness; , scar depth; , scar length; , scar width.

in scar dimensions throughout pregnancy. Steroid use

was associated with a smaller decrease in depth of the
hypoechoic part of the scar (FDR P-value = 0.07) over
time, but with an enhanced decrease in RMT over time
(FDR P-value = 0.08; Table 3).

Ultrasound Obstet Gynecol 2013; 41: 556562.

Naji et al.

560
Table 2 Cesarean section scar size and dimensions in each trimester of pregnancy
Scar characteristic

Trimester 1

Trimester 2

Trimester 3

False discovery rate P*

Scar width (mm)

Scar depth (mm)
Scar length (mm)
RMT (mm)

3.6 (3.04.7)
8.3 (6.610.2)
10.4 (8.612.7)
5.3 (4.76.2)

5.3 (4.06.6)
6.2 (5.17.5)
8.0 (7.29.9)
3.5 (2.84.2)

7.4 (6.18.9)
4.8 (3.75.6)
6.8 (5.98.1)
3.5 (2.53.6)

< 0.0001
< 0.0001
< 0.0001
< 0.0001

Data are shown as median (interquartile range). *One-way repeated measures ANOVA. RMT, residual myometrial thickness.
Table 3 Influence of demographic variables and obstetric history on scar characteristics throughout pregnancy
Scar characteristic

Variable of interest

Fixed effects equations*

Scar width (mm)

Age

Scar length (mm)

Age

Scar depth (mm)

Steroid use

RMT (mm)

Steroid use

Scar depth (mm)

VBAC

Scar length (mm)

VBAC

RMT (mm)

VBAC

y = 2 + 1.83 T
y = 2 + 1.12 T + 0.02 T V
y = 12.8 1.96 T
y = 12.8 1.48 T 0.015 T V
y = 10.4 1.87 T
y = 10.4 1.89 T + 0.45 T V
y = 6.34 1.13 T
y = 6.34 1.12 T 0.22 T V
y = 10.4 1.87 T
y = 10.4 1.85 T 0.22 T V
y = 12.8 1.96 T
y = 12.8 1.93 T 0.23 T V
y = 6.34 1.13 T
y = 6.34 1.14 T + 0.15 T V

False discovery rate P

0.024

0.11

0.045

0.11

0.015

0.07

0.032

0.08

0.042

0.066

0.026

0.066

0.019

0.066

*Fixed effects equations from mixed models with and without the relevant interaction term are shown in each case. RMT, residual
myometrial thickness; T, trimester coded as 1, 2 or 3 for first, second and third trimester, respectively; V, variable of interest; VBAC, vaginal
birth after Cesarean section.

Influence of previous obstetric history on change in scar

size
Depth and length of the hypoechoic part of the scar
were found to decrease more rapidly over time in women
who had a previous successful trial of VBAC (FDR Pvalues = 0.066). The opposite trend was observed for
RMT, with less of a decrease over time in cases with
a previously successful VBAC (FDR P-value = 0.066).
When multivariable analysis was carried out to investigate
the influence of both maternal age and previous successful
trial of VBAC on scar changes throughout the course
of pregnancy, they were found to enhance the decrease
in length of the hypoechoic part independent of each
other (FDR P-values = 0.14). The change in width of the
hypoechoic part of the scar was significantly influenced by
maternal age, but adding history of VBAC to the model
did not affect the pattern of change. Similarly, the change
in depth of the hypoechoic part of the scar and RMT were
significantly influenced by history of VBAC, but without
influence of maternal age. No significant association was
found between scar size and the number of previous CSs
or history of postpartum infection.

DISCUSSION
We have shown that the dimensions of CS scars are not
static and change in a similar way over the course of
pregnancy in the majority of women. We have observed
that the larger the depth and length of the hypoechoic

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

apparent defect in the first trimester of pregnancy,

the greater the decrease in these dimensions over the
remainder of the pregnancy. The same relationship holds
for RMT. Our data also show that in women with
a previous successful VBAC the hypoechoic apparent
defect of CS scars is smaller while RMT is larger. Our
observations establish the natural history of both the
hypoechoic apparent defect and RMT components of
CS scars that can be visualized using ultrasound.
To date, the literature has focused on appearance of CS
scars in the non-pregnant state or on single assessments
of scar size or morphology19 . However, our study shows
for the first time that both the size of the hypoechoic part
of CS scar and RMT change as pregnancy progresses.
Accordingly, any interpretation of scar morphology and
size, as well as changes in scar size, must take into account
the gestational age at which observations are carried out.
The strengths of this study are the relatively large
sample size and the prospective design. A weakness is that
in 11% of scans the CS scar was not visible to operators.
It seems likely that a poorly visible scar has an absent
hypoechoic apparent defect and a correspondingly larger
RMT. Of the 36 cases in which the scar was not visible the
uterus was retroverted in the majority, while the scar was
almost always visible when the uterus was anteverted. This
discrepancy may relate to tension being put on the scar by
the position of the uterus; when retroverted the internal
cavity surface of the lower segment is brought together and
a smaller scar may result, hence limiting its visibility. From
a practical clinical viewpoint, this study was designed

Ultrasound Obstet Gynecol 2013; 41: 556562.

Cesarean section scars during pregnancy

to fit in with routine clinical management, i.e. nuchal
translucency measurement in the first trimester, fetal
biometry and anomaly screening in the second trimester
and scans for fetal growth assessment in the third trimester
where applicable. The time slot was not increased to
accommodate additional transvaginal ultrasound scans;
thus, the addition of TVS in this context would be unlikely
to add significantly to a units workload.
Our data demonstrate that the length of the hypoechoic
part of the scar showed a greater rate of decrease during
pregnancy in women who had undergone previous VBAC,
but that there was less of a decrease in RMT over time
in these women. On the other hand, there were two cases
of uterine scar rupture and five cases of dehiscence in the
group of women who had a trial of VBAC in this study.
It is interesting to note that the two cases of scar rupture
involved one previous CS and these women were offered
a trial of VBAC. However, both underwent emergency
CS for suspected uterine scar rupture that was confirmed
intraoperatively. In retrospect, these cases can be seen
as having demonstrated a different pattern of changes
in RMT in comparison to the rest of the cohort. Both
women had an RMT of 0.5 mm in the second trimester,
and a decrease in RMT between the first and second
trimesters of 2.7 and 2.5 mm, respectively. This difference
is important, as these cases could have been identified as
being at high risk of failing a trial of VBAC from as early
as 20 weeks gestation.
The observation of changes in dimensions of different
parts of CS scars over the course of pregnancy offers
a novel potential approach to evaluating scar integrity.
This could be helpful as the use of single parameters
may be problematic. It was reported previously that LUS
thickness of < 2.3 mm is associated with a higher risk of
complete uterine rupture20 and a systematic review by
Jastrow et al. on the diagnostic accuracy of sonographic
LUS measurements at 3639 weeks to predict uterine scar
rupture revealed that the optimal cut-off values for partial
thickness ranged from 1.42.0 mm. However, due to the
heterogeneity of the studies included in the review, the
authors were unable to recommend ideal cut-off values to
be used in practice16 .
We have previously shown that there is good
interobserver agreement for measurement of both the
hypoechoic part of CS scars and RMT in all three
trimesters of pregnancy21 . Therefore, should either the
scar measurements at a specific gestational age or the rate
of change in scar size be a predictor of scar integrity, it may
be possible to develop a reproducible ultrasound-based
test that might contribute to selection of women suitable
for a trial of VBAC. A prospective study to evaluate the
relationship between these ultrasound features and scar
performance in labor is needed to address this possibility.
It is interesting to note that smoking, infection following
a previous CS and the number of previous CSs had no
significant effect on changes in scar dimensions during
pregnancy, although these factors might be expected to
affect scar healing22 .

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

561

Maternal age also had a significant impact on changes

in scar dimensions during pregnancy. The greater the age
of the patient, the more pronounced was the decrease in
length and the increase in width of the hypoechoic part
of the scar over the course of pregnancy. It is well known
that the physiological changes associated with aging place
older patients at higher risk of poor wound healing23 ,
and that reduced skin elasticity and collagen replacement
influence healing24 . Steroid use was associated with a
lesser decrease in depth of the hypoechoic part of the
scar but a greater decrease in RMT. Interestingly, there
was a significant difference in the change in RMT
between women with a previous successful VBAC and
the rest of the study group. The overall decrease in RMT
measurements throughout pregnancy was less in women
who had undergone a previous successful VBAC, while
the length and depth of the hypoechoic part of the scar
decreased more rapidly in this group. These observations
may help shed light on the mechanism of CS scar integrity.
Reduction in size of the hypoechoic apparent defect may
not imply scar weakness. The finding that RMT reduces
less rapidly in women who have had a successful VBAC
suggests that RMT may be a more important indicator of
scar integrity.
Giving women choice and control with regard to
childbirth is a significant driver in modern obstetrics and it
is axiomatic that womens decisions should be informed.
While achieving a vaginal delivery after a previous CS
is considered the optimal outcome, attempting a VBAC
when there is little or no chance of success may not be a
choice that a woman would want to make. Furthermore,
predicting serious complications such as rupture and
dehiscence is important because of the accompanying
morbidity. We have described reference data relating to
CS scars throughout pregnancy. Our observations suggest
that RMT remains relatively static and greater in women
who have had a previous successful VBAC. Conversely,
the opposite was true in the small number of cases in the
study group with adverse scar outcomes. These differences
could be observed as early as at 20 weeks gestation. These
findings support the view that absolute measurements and
changes in scar dimensions between 12 and 20 weeks
gestation have the potential to be incorporated into
algorithms used to advise women regarding the likely
success of a trial of VBAC.

ACKNOWLEDGMENT
T. Bourne is supported by the Imperial Healthcare NHS
Trust NIHR Biomedical Research Centre.

REFERENCES
1. Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH.
Detection of cesarean scars by transvaginal ultrasound. Obstet
Gynecol 2003; 101: 6165.
2. Bij de Vaate AJ, Brolmann HA, van der Voet LF, van der
Slikke JW, Veersema S, Huirne JA. Ultrasound evaluation of
the Cesarean scar: relation between a niche and postmenstrual
spotting. Ultrasound Obstet Gynecol 2011; 37: 9399.

Ultrasound Obstet Gynecol 2013; 41: 556562.

Naji et al.

562
3. Menada Valenzano M, Lijoi D, Mistrangelo E, Costantini S,
Ragni N. Vaginal ultrasonographic and hysterosonographic
evaluation of the low transverse incision after caesarean section:
correlation with gynaecological symptoms. Gynecol Obstet
Invest 2006; 61: 216222.
4. Burger NF, Darazs B, Boes EG. An echographic evaluation
during the early puerperium of the uterine wound after
caesarean section. J Clin Ultrasound 1982; 10: 271274.
5. Ofili-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C,
Gonzalez J, Jurkovic D. Deficient lower-segment Cesarean
section scars: prevalence and risk factors. Ultrasound Obstet
Gynecol 2008; 31: 7277.
6. Vikhareva Osser O, Jokubkiene L, Valentin L. Cesarean section
scar defects: agreement between transvaginal sonographic
findings with and without saline contrast enhancement.
Ultrasound Obstet Gynecol 2010; 35: 7583.
7. Zimmer EZ, Bardin R, Tamir A, Bronshtein M. Sonographic
imaging of cervical scars after Cesarean section. Ultrasound
Obstet Gynecol 2004; 23: 594598.
8. Stirnemann JJ, Chalouhi GE, Forner S, Saidji Y, Salomon LJ,
Bernard JP, Ville Y. First-trimester uterine scar assessment by
transvaginal ultrasound. Am J Obstet Gynecol 2011; 205: 551
e16.
9. Naji O, Abdallah Y, Bij de Vaate A, Smith A, Pexsters A,
Stalder C, McIndoe A, Ghaem-Maghami S, Lees C, Brolmann
HA, Huirne JA, Timmerman D, Bourne T. Standardized
approach for imaging and measuring Cesarean section scars
using ultrasonography. Ultrasound Obstet Gynecol 2012; 39:
252259.
10. Rozenberg P, Goffinet F, Phillippe HJ, Nisand I. Ultrasonographic measurement of lower uterine segment to assess risk of
defects of scarred uterus. Lancet 1996; 347: 281284.
11. Asakura H, Nakai A, Ishikawa G, Suzuki S, Araki T. Prediction
of uterine dehiscence by measuring lower uterine segment
thickness prior to the onset of labor: evaluation by transvaginal
ultrasonography. J Nippon Med School 2000; 67:352256.
12. Qureshi B, Inafuku K, Oshima K, Masamoto H, Kanazawa K.
Ultrasonographic evaluation of lower uterine segment to predict
the integrity and quality of cesarean scar during pregnancy: a
prospective study. Tohoku J Exp Med 1997; 183: 5565.
13. Gotoh H, Masuzaki H, Yoshida A, Yoshimura S, Miyamura T,
Ishimaru T. Predicting incomplete uterine rupture with vaginal

Copyright 2012 ISUOG. Published by John Wiley & Sons Ltd.

14.

15.

16.

17.
18.

19.

20.

21.

22.

23.
24.

sonography during the late second trimester in women with

prior cesarean. Obstet Gynecol 2000; 95: 596600.
Sen S, Malik S, Salhan S. Ultrasonographic evaluation of lower
uterine segment thickness in patients of previous cesarean
section. Int J Gynaecol Obstet 2004; 87: 215219.
McMahon MJ, Luther ER, Bowes WA, Jr., Olshan AF.
Comparison of a trial of labor with an elective second cesarean
section. N Engl J Med 1996; 335: 689695.
Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y,
Bujold E. Sonographic lower uterine segment thickness and risk
of uterine scar defect: a systematic review. J Obstet Gynaecol
Can 2010; 32: 321327.
Ozdemir I, Yucel N, Yucel O. Rupture of the pregnant uterus:
a 9-year review. Arch Gynecol Obstet 2005; 272: 229231.
Klipper-Aurbach Y, Wasserman M, Braunspiegel-Weintrob N,
Borstein D, Peleg S, Assa S, Karp M, Benjamini Y, Hochberg
Y, Laron Z. Mathematical formulae for the prediction of the
residual beta cell function during the first two years of disease
in children and adolescents with insulin-dependent diabetes
mellitus. Med Hypotheses 1995; 45: 486490.
Vikhareva Osser O, Valentin L. Clinical importance of
appearance of cesarean hysterotomy scar at transvaginal
ultrasonography in nonpregnant women. Obstet Gynecol 2011;
117: 525532.
Bujold E, Jastrow N, Simoneau J, Brunet S, Gauthier
RJ. Prediction of complete uterine rupture by sonographic
evaluation of the lower uterine segment. Am J Obstet Gynecol
2009; 201: 320 e16.
Naji O, Daemen A, Smith A, Abdallah Y, Saso S, Stalder
C, Sayasneh A, McIndoe A, Ghaem-Maghami S, Timmerman
D, Bourne T. Visibility and measurement of cesarean section
scars in pregnancy: a reproducibility study. Ultrasound Obstet
Gynecol 2012; 40: 549556.
Schugart RC, Friedman A, Zhao R, Sen CK. Wound
angiogenesis as a function of tissue oxygen tension: a
mathematical model. Proc Natl Acad Sci USA 2008; 105:
26282633.
Pittman J. Effect of aging on wound healing: current concepts.
J Wound Ostomy Continence Nurs 2007; 34: 412415.
Roeder HA, Cramer SF, Leppert PC. A look at uterine wound
healing through a histopathological study of uterine scars.
Reprod Sci 2012; 19: 463473.

Ultrasound Obstet Gynecol 2013; 41: 556562.