Predicting Uterine Rupture Risk Using Lower Uterine Segment Measurement During Pregnancy With Cesarean History: How Reliable Is It? A Review

Abstract

Importance Uterine rupture during labor is a calamitous event that can result in maternal/neonatal morbidity/mortality. Lower uterine segment (LUS) thickness measurement is a proposed method to determine the risk factor of uterine rupture in women undergoing trial of labor after cesarean. Does this measurement predict uterine rupture risk? Objectives This review examines current evidence to determine if a thin LUS ultrasound diagnosis during pregnancy with prior cesarean delivery(s) can reliably predict uterine rupture risk while attempting vaginal birth after cesarean (VBAC). Evidence Acquisition Electronic databases (PubMed and CINAHL) were searched with one limitation of abstracts in English. Search terms used were “lower uterine segment” AND “risk(s)” AND “rupture” OR “dehiscence. Results After reviewing 164 identified articles, 15 were used in this review. Of the studies including LUS thickness measurement, notable differences were found: gestational age at time of measurement, full thickness measurement versus myometrial thickness, number of sonographers involved, ultrasound technique (transabdominal vs transvaginal), and blinding. Other factors influencing LUS thickness include fetal weight, amniotic fluid volume, and gestational age. The most recent systematic review and meta-analysis suggests that an LUS > 3.65 mm should be safe for a VBAC, 2–3.65 mm is probably safe, and <2 mm identifies a patient at higher risk for uterine rupture/dehiscence. Conclusions Study heterogeneity, absence of an agreed upon thickness threshold, poor correlation between ultrasound and MRI measurements, or physical cesarean measurements currently make VBAC uterine rupture risk prediction uncertain. Relevance Our aim is to analyze existing literature to determine if evidence supports LUS measurement in women undergoing VBAC after cesarean to determine risk of uterine rupture. Target Audience Obstetricians and gynecologist, family physicians Learning Objectives After completing this learning activity, the participant should be able to identify the differences and how they occur between studies evaluating the thinness of the LUS in women undergoing a trial of labor after cesarean delivery; compare the accuracy of LUS measurement between ultrasound, MRI, and physical measurement at cesarean delivery; and describe the factors that influence the thinness of the LUS.