Ultrasound Evaluation of Uterine Scar After Cesarean Section and Next Birth

DOI: 10.5455/medarh.2012.66.s41-s44
Med Arh. 2012 Jun; 66(3, suppl 1): 41-44
Received: April 25th 2012
Accepted: Junel 21st 2012

CONFLICT OF INTEREST: NONE DECLARED

ORIGINAL PAPER

Ultrasound Evaluation of Uterine Scar

After Cesarean Section and Next Birth
Ejub Basic1, Vesna Basic-Cetkovic2, Hadzo Kozaric3, Admir Rama1
Clinic of Gynecology and Obstetrics, Clinical Center of Sarajevo University, Bosnia and Herzegovina1
Institute for blood transfusion, Sarajevo, Bosnia and Herzegovina2
Private gynecology practice, Livno, Bosnia and Herzegovina3

I
ntroduction: Cesarean section (Sectio Caesarea) is a surgical method for the tension sutures - the muscular annular
completion of delivery. After various historical modifications of operative tech- and muscular serous suture allowing
niques, modern approach consists in the transverse dissection of the anterior the continuity of the wall of the uterus.
wall of the uterus. The rate of vaginal birth after cesarean section was significantly At this point, the front isthimic wall of
reduced from year to year, and the rate of repeated cesarean section is increased dur- the uterus scar remains. The scar dur-
ing the past 10 years. Evaluation of scar thickness is done by ultrasound, but it is still ing new pregnancy and especially child-
debatable size of thick scar that would be guiding cut-off value for the completion birth is the new locus minoris resisten-
of the delivery method. Goal: The aim was to examine the most accurate ultrasonic tiae and a constant danger for sponta-
method for assessing thickness scar on the uterus after previous cesarean delivery neous rupture of the uterus.
and determine the threshold thickness of scar that would allow the completion of The rate of vaginal birth after cesar-
birth vaginally. Material and methods: Conducted is prospective study of 108 ean section was significantly reduced
pregnant women aged 20-42 years, who had previously had a Caesarean section.
from year to year, and the rate of re-
Diagnostic accuracy in assessing the success of scar scale by evaluation of delivery
peated cesarean section is increased
(spontaneous or caesarean section). Measurements were carried out by 2D and 3D
during the past 10 years. Evaluation of
ultrasound machines in the 20, 38-40 week of gestation and 48 hours after birth.
scar thickness is done by ultrasound,
Results: Tests have shown that there is a statistically significant difference in the
rates of specificity (0.04), sensitivity (0.05), PPV (0.01) and NPV (0.01) between 2D but it is still debatable scar thickness
and 3D ultrasound. Ultrasound images of uterine muscle scar after prior cesarean that would be guiding cut-off value
section are better by 3D methods. The marginal value, cut-off value thick scar, for the completion of the delivery by
which provides the possibility of vaginal birth after previous incision was 3.5 mm. vaginal method (J Dodd et al., 2004) (1).
Conclusion: The study showed that ultrasound measurement of 3D ultrasound In recent years, the most common
thick scar on the uterus after previous cesarean section has practical application indication for cesarean section is the
in determining the mode of delivery among pregnant women who have previously previous cesarean section delivery.
given birth by Caesarean section. Key words: uterus, scar, ultrasound. Since 1996 in the U.S. started the
active promotion of the natural vaginal
Corresponding author: Ejub Basic, MD, PhD. Clinic of Gynecology and Obstretics, Clinical center of birth after previous cesarean deliveries,
University of Sarajevo, Bosnia and Herzegovina. all with the aim to:
Reduce the rate of repeated cesar-
ean delivery.
1. INTRODUCTION niques, modern approach consists in Improve quality and shorten re-
Cesarean section (Sectio Caesarea) the transverse dissection of the anterior covery time of mothers in the
is a surgical method for the comple- wall of the uterus. Anatomical restitu- postpartum period.
tion of delivery. After various histor- tion of the incision is made in the sur- Increase the rate of vaginal births.
ical modifications of operative tech- gical treatment by individual and/or ex- To minimize delivery complications.

Med Arh. 2012 Jun; 66(3, suppl 1): 41-44 Original paper 41
Ultrasound Evaluation of Uterine Scar After Cesarean Section and Next Birth

Create economic preconditions CESARIAN VAGINAL tent risk of uterine rup-

Compared deliveries
SECTION DELIVERY
for a more economical way to 2nd MEASUREMENT : 1st
ture in the scar area.
complete delivery. MEASUREMENT: Therefore, appropri-
It is noticeable that the rate of at- Average differentiation: d d = -0.58 mm d = -0.49 mm ate and timely assess-
tempted vaginal birth after previous Stand. deviation of
SDdif = 0.38 SDdif = 0.249
ment of uterine scar is
cesarean delivery decreased, but the differentiation of great importance for
t= 6.70 SIGN. t= 5.953 SIGN.
success rate of such births increased. t-test of differentiation making the right deci-
p<0.001 p<0.001
This is the result of a good selection 3rd MEASUREMENT : 2nd sions on the comple-
of mothers and adequate quality of ul- MEASUREMENT: tion of pregnancy. The
trasound assessment of uterine scar. Average differentiation: d d = -1.35 mm d = -0.65 mm aim of this study was
The frequency of cesarean delivery in Stand. deviation4 of
SDdif = 0.568 SDdif = 0.388 to confirm a reliable
differentiation
the U.S. was in 1970 5.5%. This figure ultrasonic inspection
In 20threaching
gestational 27.6%
week in t= 6.968 SIGN. t= 5.759 SIGN.
gradually increased, t-test of differentiation
p<0.001 p<0.001
method and set the
2003 when the from ten vaginal deliv- 3rd MEASUREMENT : 1st cut-off value of scar
The second examination
eries one was completed
Between 38surgically
th th (2). weeks
and 40 gestational MEASUREMENT: thickness that would
Its been a whole century from sen- Average differentiation: d d = -1.93 mm d = -1.56 mm be guiding the manner
tence of EdwardThe third examination
Cragin Once cesar- Stand. deviation of
SDdif = 0.65 SDdif = 0.47 of delivery completion.
Postpartum examination (48 hours after differentiation
birth)
ian, always a caesarean section from
t= 7.201 SIGN. t= 6.139 SIGN.
1916. In 2003 in Ultrasonic
the U.S.methods
in 31% areof all by
controlled
t-test of differentiation
tests of sensitivity and specificity.p<0.001Youden statistical test
p<0.001 2. GOAL
deliveries completed
(J) wasby caesarean
used as a summary sec-(total) validity index that takes into account the sensitivity and The aim was to ex-
tion belonged to specificity.
the repeated cesarean Table 1. The average difference of scar thickness between amine the most accu-
sections, making this method one of measurements rate ultrasonic method
the leading causes. In 1980 the Com- for assessing thick scar
4. RESULTS
mission of the National Institute of the have caesarian section. This can result on the uterus after previous cesarean
United States considersResults
the need for re- by tables
are presented in increased
and graphs. maternal and fetal morbid- delivery and determine the threshold
peated cesarean delivery and concluded ity and mortality. The decision on the thick scar that would allow the com-
that in properly selected patients vagi- mode of delivery in pregnant women pletion of birth vaginally.
Figure 1. Age of patients according to the method of delivery at the Gynecology and
nal delivery may Obstetrics
be possible Cliniceven within 2007
Sarajevo previously
- representationdelivered
of womenby by caesarean
age groups sec-
the transverse uterine scar from a ce- tion is not easy, since there is often a la- 3. MATERIAL AND METHODS
sarean section (3). Observational, prospective cohort
Public Health Ser- 20 18 18
17
study includes 108 women over a period
18
vice in the U.S. in 1990 16 of one year was performed at the Gyne-
14
suggested that from the 14 13 cology and Obstetrics Clinic, Clinical
No. of women

12
total number of births 10
10 Center of Sarajevo University.
15% being completed by 8 6
Criteria for inclusion in the study
caesarean section, and 6 5
were:
4 3
35% of vaginal births 2
2 2 Pregnant women who have pre-
0
after previous cesarean 0 viously had a caesarean section,
21 - 24 25 - 29 30 - 34 35 - 39 40 - 42 Unknown
section. This result is with an unlimited number of vag-
Age
supposed to be reached Cesarian section Vaginal delivery inal deliveries.
until 2000. As a result Figure 1. Age of patients according to the method of delivery at the A low transverse section.
of this recommendation Gynecology and Obstetrics Clinic Sarajevo in 2007 - representation Informed consent.
the number of vaginal of women by age groups Singleton pregnancies.
The sec-
birth after cesarean difference in the average age of women depending on the mode of the last delivery: cesareanMethods
6
section/vaginal delivery - is not statistically significant. The value of t-test was: t = 0.299
tion increased from 3% History of pregnancy.
in 1980 to 20% in 1990 2nd measurement : 1st 3rd measurement : 2nd 3rd measurement : 1st Clinical examination of pregnant
measurement measurement measurement
and in 1996 amounted 0 women.
to 28%. Number of vag- 2D ultrasound.
Average differentiation d

-0,5
inal deliveries in Gyne- -0,58
-0,49 3D ultrasound.
-0,65
cology and Obstetrics -1 Color Doppler ultrasound.
Clinic, Clinical Center -1,5
Ultrasound examinations (2D, 3D
-1,35
of Sarajevo University is -1,56 ultrasound) were performed in the fol-
in steady decline. On the -2
-1,93 lowing intervals:
other hand, increases -2,5
Compared deliveries
The first examination: In 20th gesta-
the number of cesar- Cesarian section Vaginal delivery tional week. The second examination:
ean sections, so that to- Between 38th and 40th gestational weeks.
day one in five pregnant Figure 2. The average difference between scar thicknesses between The third examination: Postpartum ex-
women in our clinic measurements amination (48 hours after birth).

st nd rd
Med Arh.Figure Average
20123.Jun; difference
suppl of
1):scar thickness in 1 , 2 and 3 the measurement
42 66(3, 41-44 Original paper
7
5,92
m
 7
Ultrasound Evaluation of Uterine Scar After Cesarean Section and Next Birth

Figure 3. Average difference of scar thickness in 1st, 2nd and 3rd the measurement
By t-test
7 average thickness of the 1st measurement: t=14.796 SIGN. p<0.001
1st measurement:
5,92 t=14,796 SIGN. p<0,001
scar between women ac- 2nd measurement: t=15.516 SIGN. p<0.001
Average scar thickness in mm

6 5,43
2nd measurement: 3rd measurement: t=18.715 SIGN. p<0.001
5
4,81 t=15,516 4,78 cording
SIGN. to the last p<0,001
birth:
4,23
4 3rd measurement: t=18,715 cesarean
SIGN. delivery - vagi-
p<0,001 The difference in the distribution of
3
2,88 nal birth by t-test women according to the thickness of
2 The difference in the the scar in 1st measurement is statisti-
1 distribution of women cally highly significant. The value of chi-
0 according to the thick- square test was 2=167.815, p<0.001.
1st measurement 2nd measurement 3rd measurement ness of the scar in the The difference in the average num-
Compared measurements
Cesarian section Vaginal delivery second measurement ber of points among women according
is statistically highly to type of previous delivery: cesarean
Figure 3. Average difference of scar thickness in 1st, 2nd and 3rd
the measurement
significant. The value section/vaginal delivery, was statisti-
Figure 4. Distribution of women according to the
of thickness of thetest
chi-square scar was
in the third
cally highly significant. The value of t-
measurement by type of the previous delivery
Ultrasonic methods are controlled 2=70.833, p<0.001. test is: t=36.762, p<0.0001.
by tests of sensitivity and In the group of women who had
Results of differences significance tests in the average thickness of the scar between women
specificity. Youden sta- Caesarean section, the difference in the
according to the last birth: cesarean
25 delivery - vaginal birth
tistical test (J) was used 21 number of women by the time elapsed
as a summary (total) va- 20 18 18
since the last C-section is not statisti-
lidity index that takes cally significant. The value of chi-square
15
into account the sensi- 9
test is: 2 = 1.67.
tivity and specificity. 10 8
18
21
6
8
6 18 In the group of women who had vag-
5 5
5 3 inal delivery, the difference in the num-
4. RESULTS
9
8
0 0 0 0 3 3 0
8
0
5
0
6
0 0
5
0 3
0
0 0
ber of women by the time elapsed since
Results are presented 0 the last C-section is statistically highly
by tables and graphs. 8 significant. The value of chi-square test
The difference in the av- Cesarian section Vaginal delivery Total is: 2 = 27.0, p<0.001.
35
erage age of women de- 29 The difference in time elapsed since
30
pending on the mode of Figure 4. Distribution of women according to the thickness of the last cesarean delivery among women
25
the last delivery:Figure cesar- scar
5. Distributionin theof third
women measurement
according toby 818type
the of the of
thickness previous
the scardelivery in the second depending on the mode of delivery in
measurement 20
ean section/vaginal de- and the type of previous delivery 14 the last pregnancy was statistically sig-
15 12
livery - is not statistically 35 28
9
8
nificant. The value of chi-square test is:
10 29 7
significant. The value of 30
13
5
4 2 = 9.706, p <0.005.
2 12 12
5
t-test was: t = 0.299 25 2 0 0 1 2 5 0
9
0
8
0
7
0 5 1 3
The difference in thickness of the
The coefficients of 0
20 3,3
18
3,5-3,9 4,0-4,4 4,5-4,9 5,0-5,2 5,3-5,4 5,5-5,7 5,8-5,9 6,0-6,2 Unknown
scar, depending on the type of cesarean
14
linear correlation be- 15 12 birth/vaginal delivery is highly statisti-
28
tween age and thickness 10
Cesarian section 9
Vaginal delivery 8
7
Total cally significant. The value of chi-square
5
of the scar in the third 5 2 12 12 13
4
test is: 2 = 82.837, p <0.0001.
9 8
measurement: 0
2 0 0 1 2 5 0 0 0
7
0 5 1 3 The diagnostic accuracy
For caesarean sec-The difference in the distribution
3,3 3,5-3,9 of women
4,0-4,4 4,5-4,9according
5,0-5,2 to
5,3-5,4 the thickness
5,5-5,7 5,8-5,9 of the
6,0-6,2 scar
Unknownin the second The diagnostic accuracy in assessing
tion: r = -0.092
measurement is statistically highly significant. The value of chi-square test was 2=70.833, the scar was made by success of deliv-
Cesarian section Vaginal delivery Total
not sign. p<0.001 ery (spontaneous or caesarean section)
For vaginal deliv- Figure 5. Distribution of women according to the thickness of the Spontane-
2 D estimate Surgical
ery: r = 0.112no scar in the second measurement and the type of previous delivery ous
The difference
Figure in the distribution
6. Distribution of women accordingof women to according
the thickness to the of thickness
the scarofand the 1scar
st in the second
measurement
sign. N = 54 22 33
measurement
and the type ofisprevious
statistically highly significant. The value of chi-square test was 2=70.833,
delivery Delivery after
The coefficients of 40 44
p<0.001 estimate
linear correlation be- 35 32
30
p 0.05 0.05
tween the number of 30
Spontane-
gestation weeks and scar
Figure 25
6. Distribution of women according to the thickness of the scar and 1st measurement
3 D estimate
ous
Surgical
thickness in theand third
the type of20previous delivery 17
N = 54 44 10
measurement: 15 32 12 Delivery after
35 32 42 12
For caesarean sec- 10 6 6
30
24 estimate
30 17 5
tion: r = -0.176 p NS NS
5 9 1
25
not sign. 0
6 0 6 0 0 3 6 0 0 1 1 3 Comparing successfulness of scar
20 17
For vaginal deliv- 3,9 4,0-4,4 4,5-4,9 5,0-5,4 5,5-5,9 6,0-6,4 6,5 and
more
Unknown
evaluation between 2D and 3D tech-
32 12
15
ery: r = 0.163no niques there is a significant statistical
Cesarian section Vaginal delivery
24 Total
sign. 10 6 6
17 5 difference (p<0.01), and it was 98% (3D)
Results of differences Figure 5 6. Distribution of women9according to the thickness
6 0 6 0 6
1 of the compared to 66% (2D) false-positive es-
significance tests in the scar0and 1st measurement0 and the type of previous delivery
3 0 0 1 1 3

3,9 4,0-4,4 4,5-4,9 5,0-5,4 5,5-5,9 6,0-6,4 6,5 and Unknown

timates by 2D is 52% and for 3D was 4%,
more

Cesarian section Vaginal delivery Total

Med Arh. 2012 Jun; 66(3, suppl 1): 41-44 Original paper 43
 The difference in the distribution of women according to the thickness of the scar in 1st
measurement is statistically highly significant. The value of chi-square test was 2=167.815,
p<0.001

Ultrasound Evaluation of Uterine Scar After Cesarean Section and Next Birth
Figure 7. The difference in the average number of points among women according to type
of previous last delivery: cesarean section/vaginal delivery

40 38 5. DISCUSSION given birth by caesarean section. Since

35 Cesarian section Vaginal delivery
By measuring the thickness of the 1996 in the U.S. are trying to access the
30
scar on the uterus, after a previous ce- active promotion of the natural vaginal
No. of women

25
sarean section, we came to the cut off birth after previous cesarean section
21 20
20 18

15 that allows the vaginal delivery. That and assuming all; Reduce the rate of re-
value was 3.5 mm. peated caesarean sections; Improve the
10
6
5 3
0 1 1
0
0 0 0 0 0
Similar results were obtained by quality and recovery time for women in
7 8 9 11 12 13 14
Total score Rozenberg et al. (1996, 1997) (4), which the birth process; Increase rate of vag-
Figure 7. The difference in the average number of points among ultrasonically measured thickness of inal births; Minimize delivery compli-
women
in theaccording to type of of points
previous last delivery: cesareanto type of previous
The difference average number
section/vaginal
delivery: cesarean delivery
section/vaginal
among women according
delivery, was statistically highly significant. The value of t-
the uterine scar in pregnant women cations; Create economic preconditions
test is: t=36.762, p<0.0001
10
with previous caesarean section in as- for a cheaper way to complete delivery.
Figure 8. The time elapsed since the last C-section sessing the risk of uterine rupture in the After each successful birth by vagi-
45
current pregnancy. The authors showed nal, the natural way after cesarean de-
42
40
35
35 that the cut-off value for the size of the livery has been a request to perform
30
No. of women

25
25
scar is 3.5 mm and the evaluation was a manual review of the uterus and to
20
15
performed using ultrasound. The sen- track whether the scar on the uterus
10 6 sitivity of the ultrasound was 88% and remains intact.
5
0
specificity of 73.2%. At the same time
Less than 2 years
Cesarian section
More than 2 years
Vaginal delivery
the positive predictive value of ultra- 6. CONCLUSION
sound method was 11.8% and negative From these results we can conclude
Figure 8. The time elapsed since the last C-section
1. In the group of women who had Caesarean section, 11 the difference in the number of women
99.3% (Rosenberg et al., Lancet, 1996; that the ultrasonic measurement of
by the time elapsed since the last C-section is not statistically significant. The value of chi-
square test is: 2 = 1.67
J Gynecol Obstet Biol Reprod (Paris) thickness of the scar on the uterus has
60
2. In the group of women who had vaginal delivery, the difference in the number of women(1997). Also Rosenberg et al. showed practical application in the decision
54
by
48
the time elapsed since the last C-section is statistically highly significant. The value of chi-
50 Cesarian section Vaginal delivery
square test is: 2 = 27.0, p<0.001 40
3. The difference in time elapsed since last cesarean delivery among women depending on the
that the risk of rupture is directly pro- on the mode of delivery among preg-
No. of women

mode of delivery in the last pregnancy was statistically significant. The value of chi-square
test is: 2 = 9.706, p <0.005
30 portional to the thinning of the lower nant women who have previously given
20
uterine segment, which is analyzed in birth by Caesarean section. With ultra-
Figure 9. The thickness of the scar 10

0
0 1 0
5
the 37th gestational week. sound, antenatal measurement of scar
<3,5mm =3,5mm >3,5mm
Study by Montanari et al. (1999) (5) thickness doctor gives certainty to the
Figure 9. The thickness of the scar has questioned the accuracy of trans- decision on the completion of vaginal
The difference in thickness of the scar, depending on the type of cesarean birth/vaginal
vaginal ultrasound in the assessment of delivery and while reducing, caesar-
while false-negative assessment of 2D the lower uterine segment in pregnant
delivery is highly statistically significant. The value of chi-square test is: 2 = 82.837, p <0.0001
ean section rates as by the recommen-
was 44%accuracy
The diagnostic and 10% in case of 3D. women with previous caesarean sec- dations of the World Health Organi-
Sensitivity 2D 3D p
The diagnostic accuracy in assessing the scar was made by success of delivery (spontaneous or
tion. The study has established a scor- zation and the worlds leading associa-
A/A+C
caesarean section) 30/54 52/54 ing thickness of the scar on the uterus tion of obstetricians and gynecologists.
2 D estimate Spontaneous Surgical
%N = 54
Delivery after estimate
55% 22
40
95% 0.05 33
44
in the following way: Tests have shown that the method of
p
Specificity 2D
0.05
3D p
0.05
Score 1 (well-formed scar): mean choice for assessment of uterine wall
D/B+D
3 D estimate
N = 54 32/54
Spontaneous
44 48/54 Surgical
10 thickness: 4.2 mm 2.5 mm; scar thickness is 3D ultrasound tech-
Delivery after estimate 42 12
%p 53% NS 83% 0.04 NS Score 2 (poorly formed scar): 2.8 nique and a threshold value of scar
PPVComparing successfulness of scar2D 3D 2D and 3D techniques
evaluation between p there is a mm 1:06 mm, which implies that the thickness 3.5 mm.
significant statistical difference (p<0.01), and it was 98% (3D) compared to 66% (2D) false-
A/A+B 30/54 50/54 stimulation of labors in case of scoring
% 55% 93% 0.09 2 is associated with a significantly in- REFERENCES
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A/C+D 31/54 51/54 Sensitivity and specificity of ultraso- with a single prior Caesarean birth: a systematic
review of the literature. Aust N Z J Obstet Gyn-
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Vaginal delivery in patients with a prior cesar-
There was a statistically significant sound was 60.7% and negative predic- ean section. Obstet Gynecol. 1982; 59: 135-148.
difference in the rates of specificity (0.04), tive value 100% (5). 3. Cragin EB.Conservatism in obstetrics NY Med
J. 1916: 103: 1-3.
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(0.01) between 2D and 3D ultrasound im- amined the percentage of successful Echographic measurement of the inferior uterine
age of the muscle scar of the uterus after vaginal delivery in pregnant women segment for assessing the risk of uterine rupture.
J Gynecol Obstet Biol Reprod. 1997; 26: 513-519.
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44 Med Arh. 2012 Jun; 66(3, suppl 1): 41-44 Original paper