Original Research ajog.

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1 OBSTETRICS 56
2 57
3 Lower uterine segment thickness to prevent uterine 58
4
5
rupture and adverse perinatal outcomes: a multicenter 59
60
6 prospective study 61
7 62
Q7 Nicole Jastrow, MD; Suzanne Demers, MD; Nils Chaillet, PhD; Mario Girard,



;
8 63
Robert J. Gauthier, MD; Jean-Charles Pasquier, MD, PhD; Belkacem Abdous, PhD;
9 64
Chantale Vachon-Marceau, MD; Sylvie Marcoux, MD, PhD; Olivier Irion, MD;
10 Q1
65
Normand Brassard, MD; Michel Boulvain, MD, PhD; Emmanuel Bujold, MD, MSc
11 66
12 67
13 68
14 BACKGROUND: Choice of delivery route after previous cesarean rupture, which was defined as requiring urgent laparotomy. We calculated 69
delivery can be difficult because both trial of labor after cesarean delivery that 942 women who were undergoing a trial of labor after cesarean 70
15
and elective repeat cesarean delivery are associated with risks. The major delivery should be included to be able to show a risk of uterine rupture
16 71
risk that is associated with trial of labor after cesarean delivery is uterine <0.8%.
17 72
rupture that requires emergency laparotomy. RESULTS: We recruited 1856 women, of whom 1849 (99%) had a
18 73
OBJECTIVE: This study aimed to estimate the occurrence of uterine complete follow-up data. Lower uterine segment thickness was <2.0 mm
19 rupture during trial of labor after cesarean delivery when lower uterine in 194 women (11%), 2.0e2.4 mm in 217 women (12%), and 2.5 mm
74
20 segment thickness measurement is included in the decision-making in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 75
21 process about the route of delivery. 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no 76
22 STUDY DESIGN: In 4 tertiary-care centers, we prospectively recruited symptomatic uterine ruptures, which is a rate that was lower than the 77
23 women between 34 and 38 weeks of gestation who were contemplating a 0.8% expected rate (P.0001). 78
24 vaginal birth after a previous single low-transverse cesarean delivery. CONCLUSION: The inclusion of lower uterine segment thickness 79
25 Lower uterine segment thickness was measured by ultrasound imaging measurement in the decision of the route of delivery allows a low risk of 80
26 and integrated in the decision of delivery route. According to lower uterine uterine rupture during trial of labor after cesarean delivery. 81
27 segment thickness, women were classified in 3 risk categories for uterine 82
28 rupture: high risk (less than 2.0 mm), intermediate risk (2.0e2.4 mm), and Key words: lower uterine segment, uterine rupture, vaginal birth after 83
29 low risk (2.5 mm). Our primary outcome was symptomatic uterine cesarean delivery 84
30 85
31 86
32
33
34
I n the last 3 decades, the rate of ce-
sarean deliveries has been rising
continuously worldwide and has
perform an elective repeat cesarean de-
livery (ERC). ECR will reduce the risk of
uterine rupture but can also be associ-
uterine scar defect at delivery of 16% of
women when the LUS thickness was Q4
<2.5 mm compared with 0.7% when the
87
88
89
35 reached >30% in many countries. A ated with risks of short-term maternal thickness was 3.5 mm or more.13 More 90
36 major contributor to this trend is the complications, such as hemorrhage, recently, a LUS thickness of <2.3 mm 91
37 concomitant decline in the percentage of hysterectomy, thromboembolism, and was identied as a signicant risk factor 92
38 trial of labor after cesarean delivery neonatal complications that include for uterine rupture.14 Although meta- 93
39 (TOLAC) and vaginal birth after cesar- respiratory distress syndrome.5-7 In analyses report no LUS thickness cut- 94
40 ean delivery (VBAC).1 Fear of intra- addition, cesarean delivery is associated off that can predict all uterine ruptures, 95
41 partum uterine rupture, a rare with a higher risk of longer term com- most authors agree that the risk is high 96
42 (0.4e1.1%) but potentially catastrophic plications, such as placenta praevia and when the LUS thickness is <2.0 mm.10,11 97
43 complication of TOLAC, represents the accreta in future pregnancies.8,9 There- We aimed to evaluate the occurrence 98
44 main reason for this trend.2 Uterine fore, the selection of the good candidate of uterine rupture when LUS thickness 99
45 rupture can lead to perinatal asphyxia or who is at low risk for uterine rupture measurement was included in the deci- 100
46 death and severe maternal complica- during TOLAC is crucial. sion about delivery route in a large 101
47 tions.3,4 The alternative for TOLAC is to Assessment of lower uterine segment cohort of women who wanted to attempt 102
48 (LUS) thickness by ultrasound imaging TOLAC. 103
49 in the third trimester of pregnancy has 104
50 Cite this article as: Jastrow N, Demers S, Chaillet N, been proposed to predict the risk of Materials and Methods 105
51 et al. Lower uterine segment thickness to prevent uterine uterine rupture.10-14 A landmark study Study design and participants 106
rupture and adverse perinatal outcomes: a multicenter
52 by Rozenberg et al13 showed that the risk We conducted a prospective cohort 107
prospective study. Am J Obstet Gynecol 2016;


:



.
53 of a defective scar at delivery (uterine study between April 2009 and June 2013 108
54 0002-9378/$36.00 scar dehiscence and uterine rupture) is in 3 Canadian Hospitals (Centre Hos- 109
2016 Elsevier Inc. All rights reserved.
55 http://dx.doi.org/10.1016/j.ajog.2016.06.018 related directly to the degree of thinning pitalier Universitaire de Qubec, 110
of the LUS. They reported a risk of Qubec; Centre Hospitalier Universitaire

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111 167
112 Sainte-Justine, Montreal; Centre Hospi- Healthcare, Milwaukee, WI) between 34 delivery (recurrent or not), previous 168
113 talier Universitaire Fleurimont, Sher- weeks 0 days and 38 weeks 6 days of vaginal birth, and estimated fetal weight. 169
114 brooke) and a Swiss Hospital (Hpitaux gestation by a trained sonographer or Finally, women were informed that 170
115 Universitaires de Genve, Geneva). We midwife who was supervised by a mode of delivery would be discussed 171
116 recruited women who were contem- maternal-fetal medicine specialist in again in case of induction of labor or in 172
117 plating a TOLAC with a single previous each center. At least 6 measurements (3 case of labor dystocia. The institutional 173
118 low-transverse cesarean delivery and a transabdominal and 3 transvaginal) of ethics committee in each center 174
119 singleton pregnancy in cephalic presen- the LUS thickness were performed, with approved the study. Medical records 175
120 tation. The likelihood of VBAC and the the use of the method previously were reviewed for obstetric and neonatal 176
121 risk of uterine rupture were evaluated described (Figure).14 The thinnest LUS outcomes after delivery. F1
177
122 and discussed between 34 weeks 0 days value was retained. Fetal biometry (head Our primary outcome was symptom- 178
123 and 38 weeks 6 days of gestation. circumference, biparietal diameter, atic uterine rupture, dened as a com- 179
124 abdominal circumference, femur length) plete separation of the uterine scar that 180
125 Procedures was measured to estimate fetal weight resulted in protrusion of fetal or placental 181
126 After informed consent was obtained with the use of the Hadlock formula.15 parts in the peritoneal cavity and required 182
127 from the participant, a research nurse or According to LUS thickness, women urgent laparotomy. Secondary outcomes 183
128 midwife recorded maternal characteris- were classied in 3 risk categories for included incidental scar disruption 184
129 tics and medical and reproductive uterine rupture during TOLAC: high (complete opening of the previous scar 185
130 history, including the features of the risk (<2.0 mm), intermediate risk without protrusion of fetal or placental 186
131 previous cesarean delivery. Body mass (2.0e2.4 mm), and low risk (2.5 mm). parts in the peritoneal cavity) and uterine 187
132 index was calculated with the use of the Participants and their health care pro- scar dehiscence (dened as a small win- 188
133 maternal weight at inclusion (end of viders were informed of the risk cate- dow in the LUS) that was diagnosed 189
134 pregnancy). Tobacco use was considered gory. All participants met with the during cesarean delivery. A routine 190
135 when the woman was currently smok- obstetrician after the LUS assessment. manual revision of the LUS integrity was 191
136 ing. Diabetes mellitus included gesta- During this consultation, each woman not performed after vaginal birth. 192
137 tional and pregestational diabetes was informed about her risk of uterine Other secondary outcomes included 193
138 mellitus. Previous cesarean delivery that rupture during TOLAC according to the rates of TOLAC and VBAC, maternal 194
139 was performed for labor dystocia, ceph- LUS thickness (average of 0.5e1%, most outcomes (postpartum hysterectomy, 195
140 alopelvic disproportion, descent arrest, likely >1% when LUS is <2.0 mm and blood transfusion, and maternal death), 196
141 or failure to progress was reported as most likely <0.5% when LUS thickness neonatal outcomes (5-minute Apgar 197
142 previous cesarean delivery for recurrent is 2.5 mm); the consequences of score <7, cord blood pH <7.0, perinatal 198
143 reason. uterine rupture (including perinatal asphyxia [dened as a 5-minute Apgar 199
144 Examination of the LUS was asphyxia and death), the maternal and score <4, a cord blood pH <7.0 when 200
145 performed with transabdominal and neonatal complications of ECR, and the available], and evidence of altered 201
146 transvaginal ultrasound imaging with chances of successful VBAC based on neurologic status, and/or multisystem 202
147 Voluson Expert or Voluson E8 (GE the indication of previous cesarean organ failure), and intrapartum or 203
148 neonatal death. 204
149 205
150 Statistical analysis 206
FIGURE
151 Labor and delivery characteristics and 207
Lower uterine segment thickness
152 uterine scar defects were reported 208
according to LUS thickness categories
web 4C=FPO

153 209
154 (<2.0 mm, 2.0e2.4 mm, and 2.5 210
155 mm). Neonatal and maternal outcomes 211
156 were stratied according to intended 212
157 mode of delivery. We estimated that the 213
158 use of the LUS thickness could result in a 214
159 low risk of uterine rupture in women 215
160 who undergo TOLAC. We calculated 216
161 that a minimum of 942 women who 217
162 underwent a TOLAC should be included 218
163 to exclude the value of 0.8% from our 219
164 estimate of the risk of uterine rupture 220
165 Lower uterine segment thickness measured by a A, transabdominal and a B, transvaginal scan. (1-sided test; a.05; power0.80) 221
166 Jastrow et al. Lower uterine segment thickness and uterine rupture. Am J Obstet Gynecol 2016.
should the observed risk be 0.2%. We 222
estimated that a minimum of 1450

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223 279
224 women who were contemplating VBAC recruitment (CHUQ) were more likely women who underwent repeat cesarean Q5 280
225 would need to be recruited to have at to have a LUS <2 mm (13% vs 5%, 6% delivery during labor, uterine scar de- 281
226 least 942 (65%) women who would and 9%, respectively; P<.001) or fects of any type (incidental scar 282
227 choose to attempt TOLAC. Statistical 2.0e2.4 mm (15% vs 7%, 5% and 9%, disruption or uterine scar dehiscence) 283
228 analyses were performed with SPSS respectively; P<.001). were observed more frequently in 284
229 software (version 22.0; SPSS Inc, Chi- Labor characteristics and delivery women with a LUS of 2.0e2.4 mm. 285
230 cago, IL). We calculated the condence outcomes are reported in Table 2. LUS We found a statistically signicant T2 286
231 interval for proportions using the Fisher thickness measurement had a signicant association between LUS thickness 287
232 exact method and tested the statistical impact on the choice of intended mode and uterine scar dehiscence that was 288
233 signicance of the observed proportion of delivery; women with a thin LUS were observed at repeat cesarean delivery in 289
234 compared with 0.8% using the method more likely to undergo ERC. We did not women who underwent ERC. All cases of 290
235 of the normal approximation of the observe any case of symptomatic uterine uterine scar dehiscence at ERC were 291
236 binomial distribution. rupture in the entire cohort (0%; 95% observed in women with LUS <3.0 mm. 292
237 condence interval, 0.0e0.4%). No case Adverse maternal and neonatal out- 293
238 Results of 984 TOLACs was signicantly <0.8%, comes are reported according to the 294
239 We recruited 1856 women, of whom which was the expected risk (P.0001). intended mode of delivery (Table 3). T3 295
240 >99% (n1849) had complete follow- Three cases of incidental scar disruption One woman experienced unexplained 296
241 up data. Participants characteristics are without adverse perinatal outcomes intrauterine fetal death before labor at 297
T1 described in Table 1. LUS thickness was were reported in 3 women who under- 37 weeks of gestation. She underwent
242 298
243 <2.0 mm in 194 women (11%), at went repeat cesarean delivery for labor TOLAC and had an uncomplicated 299
244 2.0e2.4 mm in 217 women (18%), and dystocia after TOLAC. All 3 women had vaginal birth. Another woman had a 300
245 2.5 mm in 1445 women (78%). All 7 no progression of cervical dilation or no fetus with hydrops; she underwent an 301
246 women who were lost to follow up had progression of fetal descent for >2 hours emergency cesarean delivery, and the 302
247 a LUS thickness 2.5 mm and had before the cesarean delivery was per- neonate died soon after delivery. The 303
248 similar characteristics as the others. We formed. Uterine scar dehiscence was only case of perinatal asphyxia that 304
249 observed that women who were observed in 22 other women who un- occurred in a woman who underwent 305
250 recruited in the center with most derwent TOLAC. Looking specically at emergency cesarean delivery for fetal 306
251 307
252 308
253 TABLE 1 309
254 Characteristics of participants at recruitment 310
255 Patients characteristics All (n1856) <2.0 mm (n194) 2.0-2.4 mm (n217) 2.5 mm (n1445) 311
256 312
Maternal age, y a
31.5  4.3 31.6  4.4 31.3  3.7 31.6  4.4
257 313
258 Body mass index, kg/m 2a
29.2  5.2 27.7  4.1 28.6  4.9 29.5  5.3 314
259 Tobacco use, n (%) 149 (8) 12 (6) 26 (12) 111 (8) 315
260 Diabetes mellitus (pregestational 144 (8) 11 (6) 16 (7) 117 (8) 316
261 or gestational), n (%) 317
262 318
Previous vaginal delivery, n (%) 305 (16) 16 (8) 46 (21) 243 (17)
263 319
264 Interdelivery interval, mo a
44.1  31.3 39.7  24.3 46.7  33.8 44.3  31.7 320
265 Previous cesarean delivery for 766 (41) 39 (20) 57 (26) 670 (46) 321
266 recurrent reason, n (%) 322
267 Gestational age at sonography, wka 36.6  1.7 36.7  0.8 36.8  0.8 36.6  1.9 323
268 Estimated fetal weight, g a
2999  396 2920  355 2997  375 3010  403
324
269 325
270 Lower uterine segment thickness, mm a
3.3  1.3 1.6  0.3 2.2  0.2 3.7  1.1 326
271 Q6 Centers, n (%) 327
272 Centre Hospitalier Universitaire (Quebec) 1081 (58) 139 (72) 164 (76) 778 (54) 328
273 329
Ste-Justine Hospital (Montreal) 340 (18) 16 (8) 16 (7) 308 (21)
274 330
275 Centre Hospitalier Universitaire (Sherbrooke) 63 (3) 4 (2) 3 (1) 56 (4) 331
276 Hopitaux Universitaires de Geneve (Geneva) 372 (20) 35 (18) 34 (16) 303 (21) 332
277 a
Data are given as mean  standard deviation. 333
278 Jastrow et al. Lower uterine segment thickness and uterine rupture. Am J Obstet Gynecol 2016. 334

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336 TABLE 2 392
337 Labor characteristics and outcomes according to the lower uterine segment thickness categories 393
338 394
339 Lower uterine segment thickness 395
340 Variable <2.0 mm (n194) 2.0e2.4 mm (n217) 2.5 mm (n1438) P value 396
341 Gestational age at delivery, wka 38.9  0.9 39.3  1.0 39.6  1.0 <0.0001 397
342 398
Elective repeat cesarean delivery, n (%) 177 (91) 123 (57) 557 (39) <.0001
343 399
344 Uterine scar dehiscence, n (%) 22 (12) 3 (2) 5 (1) <.0001 400
345 Trial of labor, n (%) 17 (9) 94 (43) 881 (61) <.0001 401
346 Induction of labor 2 (12) 11 (12) 153 (17) .32 402
347 403
Oxytocin during labor 6 (35) 32 (35) 363 (41) .37
348 404
349 Vaginal birth 14 (82) 73 (78) 585 (66) .04 405
350 Symptomatic uterine rupture 0 0 0 406
351 Incidental scar disruption 0 0 3 (0.3) .83 407
352 408
Uterine scar dehiscence 0 5 (5.3) 17 (1.9) .09
353 409
354 Any type of scar defect at cesarean delivery 0/3 5/21 (24) 20/276 (7) .02 410
355 during labor 411
356
a
Data are given as mean  standard deviation. 412
Jastrow et al. Lower uterine segment thickness and uterine rupture. Am J Obstet Gynecol 2016.
357 413
358 414
359 415
distress that was not related to a uterine decision-making process on the route of 170 women who underwent a TOLAC
360 416
361 scar defect. We observed no case of delivery results in a low risk of uterine when the LUS thickness was integrated 417
362 maternal death or postpartum hysterec- rupture during TOLAC and denitively in the decision on the route of delivery. 418
tomy, but 23 women (1.2%) received inuences the womens choice about the They observed that the introduction of
363 419
blood transfusion for postpartum hem- route of delivery. LUS thickness measurement in clinical
364 420
orrhage that was more frequent in Meta-analyses of numerous small practice led to a signicant reduction of
365 421
women who underwent a TOLAC. studies showed an association between emergency cesarean deliveries and uter-
366 422
LUS thickness and the risk of uterine scar ine scar defects, when compared with the
367 423
Comment defect at delivery.10,11 Rozenberg et al16 previous period. However, some differ-
368 424
369 Our study suggests that integrating observed no case of uterine rupture ences between the 2 studies have to be 425
370 LUS thickness measurement in the and only 2 uterine scar defects from the pointed out. First, the former study used 426
only abdominal ultrasound imaging; we
371 427
used a combination of transabdominal
372 428
TABLE 3 and transvaginal ultrasound imag-
373 429
Neonatal and maternal outcomes according to intended mode of delivery ing.17,18 Second, based on previous
374 430
literature,14 by suggesting safety, we used
375 Trial of labor Elective repeat cesarean 431
Variable (n984), n (%) delivery (n865), n (%) lower thresholds (2.0e2.5 mm instead
376 432
377 of 3.5 mm). 433
Neonatal outcomes
378 Our study conrmed the association 434
Five-minute Apgar score <7 13 (1.3) 10 (1.2) between uterine scar dehiscence that was
379 435
380 Arterial cord pH <7.0 2 (<1) 2 (<1) diagnosed at ERC and LUS thickness 436
Perinatal asphyxia a
1 (<1) 0 that was reported in published meta-
381 437
analyses.10,11 In contrast, LUS thickness
382 Intrapartum or neonatal death 0 1 (<1) 438
was not associated with uterine scar
383 439
Maternal outcome dehiscence that was diagnosed at repeat
384 440
385 Maternal blood transfusion 17 (1.7) 6 (0.7)b cesarean delivery after a failed TOLAC. 441
386 Postpartum hysterectomy 0 0 This can be explained by the fact that the 442
duration of labor and labor dystocia are
387 Maternal death 0 0 443
major risk factors for uterine scar
388 a
Defined as the combination of Apgar score at 5 minutes <4, arterial cord blood pH <7.0, and neonatal multisystemic organ
444
dehiscence.19-21 The 3 cases of incidental
389 failure; b P<.05. 445
Jastrow et al. Lower uterine segment thickness and uterine rupture. Am J Obstet Gynecol 2016. scar disruption that were observed in
390 446
our cohort occurred in women with

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447 503
448 prolonged labor dystocia. This observa- rupture. This strategy has the potential meta-analysis. Ultrasound Obstet Gynecol
504
tion highlights the importance of the to lead to an overall reduction of cesar- 2013;42:132-9.
449 11. Jastrow N, Chaillet N, Roberge S, 505
450 monitoring of labor progression in ean delivery in women with previous Morency AM, Lacasse Y, Bujold E. Sonographic 506
451 women with previous cesarean delivery. cesarean delivery by reassuring both lower uterine segment thickness and risk of 507
452 We observed only few cases of major women and clinicians about the relative uterine scar defect: a systematic review.
508
453 maternal or perinatal morbidities or safety of TOLAC. n J Obstet Gynaecol Can 2010;32:321-7.
509
death that was related to uterine scar 12. Fukuda M, Fukuda K, Mochizuki M. Exami-
454 nation of previous caesarean section scars by 510
defect among almost 1000 TOLACs. We Acknowledgments
455 ultrasound. Arch Gynecol Obstet 1988;243: 511
456 did not have the power to detect a sig- We thank the members of the Department of 221-4. 512
nicant reduction in perinatal asphyxia Obstetrics & Gynecology of Sainte-Justine 13. Rozenberg P, Gofnet F, Phillippe HJ,
457 Hospital, Montreal, QC, Canada; the Depart- 513
458 or hypoxic-ischemic encephalopathy Nisand I. Ultrasonographic measurement of
514
ment of Obstetrics & Gynecology and the lower uterine segment to assess risk of defects
459 that has been reported in approximately Department of Family Medicine of the Centre 515
of scarred uterus. Lancet 1996;347:281-4.
460 5e10% of uterine rupture or approxi- Hospitalier Universitaire de Qubec, Qubec, 14. Bujold E, Jastrow N, Simoneau J, Brunet S, 516
461 mately 0.1% of TOLAC.3 Similarly, QC, Canada; the Department of Obstetrics & Gauthier RJ. Prediction of complete uterine 517
postpartum hysterectomy was reported Gynecology of the CHU Fleurimont, Sher- rupture by sonographic evaluation of the lower
462 brooke, QC, Canada; and the Department of 518
463 in 5e20% of uterine rupture or in uterine segment. Am J Obstet Gynecol
519
Obstetrics and Gynecology of the Hpitaux
464 approximately 0.2e0.3% of ERCs.3,22 Universitaires de Genve (HUG), Geneva,
2009;201:320.e1-6.
520
15. Hadlock FP, Harrist RB, Sharman RS,
465 We believe that the low risk of uterine Switzerland, for the recruitment of women in this Deter RL, Park SK. Estimation of fetal weight 521
466 rupture that was observed in our study is study. with the use of head, body, and femur mea- 522
467 likely to translate to a reduced risk of all surements: a prospective study. Am J Obstet
523
the major morbidities that are related to References Gynecol 1985;151:333-7.
468 16. Rozenberg P, Gofnet F, Philippe HJ, 524
uterine rupture. 1. Hamilton BE, Martin JA, Ventura SJ. Births:
469 preliminary data for 2012. Natl Vital Stat Rep Nisand I. Thickness of the lower uterine 525
470 The current study has some limita- segment: its inuence in the management of 526
2013;62:1-20.
471 tions that must be considered. It is likely 2. Guise JM, McDonagh MS, Osterweil P, patients with previous cesarean sections. Eur 527
472 that women who are informed about Nygren P, Chan BK, Helfand M. Systematic re- J Obstet Gynecol Reprod Biol 1999;87:
528
473 their greater risk of uterine rupture view of the incidence and consequences of 39-45.
529
(because of thin LUS) were less likely to uterine rupture in women with previous 17. Laamme SM, Jastrow N, Girard M, Paris G,
474 caesarean section. BMJ 2004;329:19-25. Berube L, Bujold E. Pitfall in ultrasound evalua- 530
475 undergo a TOLAC, unless other favor- tion of uterine scar from prior preterm cesarean 531
3. Landon MB, Hauth JC, Leveno KJ, et al.
476 able factors (previous vaginal delivery, Maternal and perinatal outcomes associated section. AJP Rep 2011;1:65-8. 532
477 rapid progression of cervical dilation) with a trial of labor after prior cesarean delivery. 18. Boutin A, Berube L, Girard M, Bujold E. La-
533
478 were present. Therefore, we cannot N Engl J Med 2004;351:2581-9. bour before a caesarean section and the
534
speculate about the association between 4. Bujold E, Gauthier RJ, Hamilton E. Maternal morphology of the lower uterine segment in the
479 and perinatal outcomes associated with a trial of next pregnancy. J Obstet Gynaecol Can 535
480 LUS thickness and successful TOLAC 2011;33:105. 536
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481 and vaginal birth. Because the partici- Womens Health 2005;50:363-4. 19. Hamilton EF, Bujold E, McNamara H, 537
482 pants and their health care providers 5. Rageth JC, Juzi C, Grossenbacher H. De- Gauthier R, Platt RW. Dystocia among women
538
483 were informed about LUS thickness, it is livery after previous cesarean: a risk evaluation: with symptomatic uterine rupture. Am J Obstet
539
also possible that a bias was introduced Swiss Working Group of Obstetric and Gyne- Gynecol 2001;184:620-4.
484 cologic Institutions. Obstet Gynecol 1999;93: 20. Khan KS, Rizvi A. The partograph in the 540
485 in the diagnosis of uterine scar dehis- management of labor following cesarean sec- 541
332-7.
486 cence at ERC. However, the fact that all 6. Steer PJ, Modi N. Elective caesarean sec- tion. Int J Gynaecol Obstet 1995;50:151-7. 542
487 uterine scar dehiscence at ERC were tions: risks to the infant. Lancet 2009;374: 21. Bergeron ME, Jastrow N, Brassard N,
543
488 observed in women with a LUS of <3.0 675-6. Paris G, Bujold E. Sonography of lower uterine
544
mm supports the strong inverse corre- 7. Hook B, Kiwi R, Amini SB, Fanaroff A, segment thickness and prediction of uterine
489 Hack M. Neonatal morbidity after elective repeat rupture. Obstet Gynecol 2009;113:520-2. 545
490 lation between LUS thickness and the 22. McMahon MJ, Luther ER, Bowes WA Jr, 546
cesarean section and trial of labor. Pediatrics
491 risk of scar disruption. We did not have a 1997;100:348-53. Olshan AF. Comparison of a trial of labor with an 547
492 control group without LUS thickness 8. Pare E, Quinones JN, Macones GA. Vaginal elective second cesarean section. N Engl J Med
548
493 measurement; therefore, it is difcult to birth after caesarean section versus elective 1996;335:689-95.
549
estimate whether the low risk of uterine repeat caesarean section: assessment of
494 maternal downstream health outcomes. BJOG 550
495 rupture is related to the LUS thickness Author and article information 551
2006;113:75-85.
496 measurement or to other interventions 9. Ananth CV, Smulian JC, Vintzileos AM. The From the Department of Obstetrics & Gynaecology, 552
497 that could have occurred in our centers association of placenta previa with history of Faculty of Medicine, Hopitaux Universitaires de Geneve, Q2 553
498 during the same period, which included cesarean delivery and abortion: a metaanalysis. Universite de Geneve, Switzerland (Drs Jastrow, Irion, and
554
changes in counselling. Am J Obstet Gynecol 1997;177:1071-8. Boulvain); the Department of Obstetrics & Gynaecology,
499 10. Kok N, Wiersma IC, Opmeer BC, de Faculty of Medicine, Centre de recherche du Centre 555
500 In conclusion, our study shows that 556
Graaf IM, Mol BW, Pajkrt E. Sonographic mea- hospitalier universitaire de Quebec (Drs Demers, Vachon-
501 the integration of LUS thickness in the surement of the lower uterine segment thickness Marceau, Brassard, and Bujold and Mr Girard), and the 557
502 decision about the route of delivery is to predict uterine rupture during a trial of labor in Department of Social and Preventive Medicine, Faculty of 558
associated with a low risk of uterine women with a previous cesarean section: a Medicine (Drs Abdous, Marcoux, and Bujold), Universite

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Laval, Quebec, QC, Canada; the Department of Obstetrics Received March 14, 2016; revised May 3, 2016; Universite Laval, Canada. S.D. and E.B. hold a Re-
560 & Gynaecology, Faculty of Medicine, Hopital Sainte- accepted June 11, 2016. searchers salary award from the Fonds de la Recherche 616
561 Justine, Universite de Montreal, Montreal, QC, Canada Supported by the Canadian Institutes of Health du QuebeceSante. Q3 617
562 (Drs Chaillet and Gauthier); and the Department of Ob- Research (operating grant #210974), the Geneva Uni- The authors report no conflict of interest. 618
563 stetrics & Gynaecology, Faculty of Medicine, Universite de versity Hospitals (PRD #09-II-28), and the Jeanne et Corresponding author: Emmanuel Bujold, MD, MSc, 619
Sherbrooke, Sherbrooke, QC, Canada (Dr Pasquier). Jean-Louis Levesque Perinatal Research Chair at FRCSC. emmanuel.bujold@crchudequebec.ulaval.ca
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