Archives of Gynecology and Obstetrics

, Volume 299, Issue 2, pp 439–449 | Cite as

Cesarean section scar in 3 T magnetic resonance imaging and ultrasound: image characteristics and comparison of the methods

  • Janine HoffmannEmail author
  • Marc Exner
  • Kristina Bremicker
  • Matthias Grothoff
  • Patrick Stumpp
  • Susanne Schrey-Petersen
  • Holger Stepan
Maternal-Fetal Medicine



Uterine rupture during labor is a rare but life-threatening complication after previous cesarean section (CS). Prenatal risk is assessed using ultrasound thickness measurement of the lower uterine segment (LUS). Due to inhomogeneous study results, however, clinical obstetrics still lacks for standard protocols and reliable reference values. As 3 T magnetic resonance imaging (MRI) has not yet been sufficiently studied regarding LUS diagnostics after previous CS, we sought to evaluate its feasibility focusing on thickness measurements and typical characteristics of the CS-scar region in comparison to ultrasound and the intraoperative status.


In this prospective study, 25 asymptomatic patients with one previous CS and inconspicuous ultrasound findings were included. An additional 3 T MRI with either a T2-weighted Turbo-Spin-Echo or a Half Fourier-Acquired-Single-shot-Turbo-spin-Echo sequence in a sagittal orientation was performed. We analyzed categorical image quality, inter- and intra-rater reliability as well as anatomy, morphology and thickness of the LUS. Results were compared to ultrasound and intraoperative findings.


MRI provided good to excellent image quality in all patients. The imaged structures presented with a high variability in anatomy and morphology. Image characteristics indicating the uterine scar were only found in 11/25 (44%) patients. LUS thickness measurements with MRI showed good inter- and intra-rater reliability but poor agreement with ultrasound.


MRI is appropriate for additional LUS diagnostics in patients with previous CS. The strong individual variability of LUS-anatomy and morphology might explain the difficulties in establishing uniform diagnostic standards after CS.


Cesarean section Prenatal diagnosis Magnetic resonance imaging Ultrasonography Uterine rupture 


Author contributions

JH: design/methods/administration of the study, data acquisition: MRI, ultrasound and clinical data, measurements, analyzing and interpreting data, writing the manuscript; ME: administration, acquiring MRI data, MRI measurements; KB: data acquisition: MRI, MRI measurements; MG: supervision, support in writing the manuscript; PS: concept/methods, administration, data acquisition: MRI, writing the manuscript; SS-P: data acquisition: ultrasound, analyzing data/interpretations; HS: design/concept, analyzing data/interpretations, ;supervision, writing the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Guise JM, Eden K, Emeis C, Denman MA, Marshall N, Fu RR, Janik R, Nygren P, Walker M, McDonagh M (2010) Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full rep) (191):1–397Google Scholar
  2. 2.
    Cahill AG, Stamilio DM, Odibo AO, Peipert JF, Stevens EJ, Macones GA (2007) Does a maximum dose of oxytocin affect risk for uterine rupture in candidates for vaginal birth after cesarean delivery? Am J Obstet Gynecol 197(5):495.e1–495.e5CrossRefGoogle Scholar
  3. 3.
    Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW et al (2004) Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 351(25):2581–2589CrossRefGoogle Scholar
  4. 4.
    Guise J-M, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M (2004) Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. BMJ (Clinical research ed.) 329(7456):19–25CrossRefGoogle Scholar
  5. 5.
    Rozenberg P, Goffinet F, Phillippe HJ, Nisand I (1996) Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred uterus. Lancet 347(8997):281–284CrossRefGoogle Scholar
  6. 6.
    Martins WP, Barra DA, Gallarreta FMP, Nastri CO, Filho FM (2009) Lower uterine segment thickness measurement in pregnant women with previous Cesarean section: reliability analysis using two- and three-dimensional transabdominal and transvaginal ultrasound. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol 33(3):301–306CrossRefGoogle Scholar
  7. 7.
    Jastrow N, Chaillet N, Roberge S, Morency A-M, Lacasse Y, Bujold E (2010) Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can JOGC 32(4):321–327CrossRefGoogle Scholar
  8. 8.
    Jastrow N, Demers S, Chaillet N, Girard M, Gauthier RJ, Pasquier J-C et al (2016) Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study. Am J Obstet Gynecol 215(5):604.e1–604.e6CrossRefGoogle Scholar
  9. 9.
    Kok N, Wiersma IC, Opmeer BC, de Graaf IM, Mol BW, Pajkrt E (2013) Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a meta-analysis. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol 42(2):132–139CrossRefGoogle Scholar
  10. 10.
    Jastrow N, Antonelli E, Robyr R, Irion O, Boulvain M (2006) Inter- and intraobserver variability in sonographic measurement of the lower uterine segment after a previous Cesarean section. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol 27(4):420–424CrossRefGoogle Scholar
  11. 11.
    Bujold E, Jastrow N, Simoneau J, Brunet S, Gauthier RJ (2009) Prediction of complete uterine rupture by sonographic evaluation of the lower uterine segment. Am J Obstet Gynecol 201(3):320.e1–320.e6CrossRefGoogle Scholar
  12. 12.
    Cheung Vincent Y T, Constantinescu OC, Ahluwalia BS (2004) Sonographic evaluation of the lower uterine segment in patients with previous cesarean delivery. J Ultrasound Med Off J Am Inst Ultrasound Med 23(11):1441–1447Google Scholar
  13. 13.
    Committee on Obstetric Practice, Copel J, El-Sayed Y, Heine RP, Wharton KR (2017) Committee Opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol 130(4):e210–e216CrossRefGoogle Scholar
  14. 14.
    Hoffmann J (2018) Magnetic resonance imaging can be useful for advanced diagnostic of the lower uterine segment in patients after previous cesarean section. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. Google Scholar
  15. 15.
    Hebisch G, Kirkinen P, Haldemann R, Pääkköö E, Huch A, Huch R (2018) Vergleichende Untersuchung am unteren Uterinsegment nach Sectio caesarea mittels Ultraschall und Magnetresonanztomographie. Ultraschall in der Medizin (Stuttgart, Germany 1980) 15(3):112–116CrossRefGoogle Scholar
  16. 16.
    Singh N, Tripathi R, Mala YM, Dixit R, Tyagi S, Batra A (2013) Comparison of scar thickness measurements using trans-vaginal sonography and MRI in cases of pregnancy with previous caesarean section. Do they correlate with actual scar thickness? J Obstet Gynaecol J Inst Obstet Gynaecol 33(8):810–813CrossRefGoogle Scholar
  17. 17.
    Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e.V. Leitlinien, Empfehlungen, Stellungnahmen (Stand August 2010): Schwangerenbetreuung und Geburtseinleitung bei Zustand nach KaiserschnittGoogle Scholar
  18. 18.
    Qureshi B, Inafuku K, Oshima K, Masamoto H, Kanazawa K (1997) Ultrasonographic evaluation of lower uterine segment to predict the integrity and quality of cesarean scar during pregnancy: a prospective study. Tohoku J Exp Med 183(1):55–65CrossRefGoogle Scholar
  19. 19.
    Fleiss JL (1999) The design and analysis of clinical experiments. Wiley, New YorkCrossRefGoogle Scholar
  20. 20.
    Kramer MS, Feinstein AR (1981) Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 29(1):111–123CrossRefGoogle Scholar
  21. 21.
    Laflamme S-MB, Jastrow N, Girard M, Paris G, Bérubé L, Bujold E (2011) Pitfall in ultrasound evaluation of uterine scar from prior preterm cesarean section. AJP Rep 1(1):65–68CrossRefGoogle Scholar
  22. 22.
    Satpathy G, Kumar I, Matah M, Verma A (2018) Comparative accuracy of magnetic resonance morphometry and sonography in assessment of post-cesarean uterine scar. Indian J Radiol Imaging 28(2):169–174CrossRefGoogle Scholar
  23. 23.
    Singh N, Tripathi R, Mala YM, Dixit R (2015) Scar thickness measurement by transvaginal sonography in late second trimester and third trimester in pregnant patients with previous cesarean section: does sequential change in scar thickness with gestational age correlate with mode of delivery? J Ultrasound 18(2):173–178CrossRefGoogle Scholar
  24. 24.
    Jastrow N, Vikhareva O, Gauthier RJ, Irion O, Boulvain M, Bujold E (2016) Can third-trimester assessment of uterine scar in women with prior Cesarean section predict uterine rupture? Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol 47(4):410–414CrossRefGoogle Scholar
  25. 25.
    Valentin L (2013) Prediction of scar integrity and vaginal birth after caesarean delivery. Best Pract Res Clin Obstet Gynaecol 27(2):285–295CrossRefGoogle Scholar
  26. 26.
    Kumar I, Verma A, Matah M, Satpathy G (2017) Utility of multiparametric MRI in Caesarean section scar characterization and preoperative prediction of scar dehiscence: a prospective study. Acta Radiol (Stockholm, Sweden 1987) 58(7):890–896CrossRefGoogle Scholar
  27. 27.
    Kushtagi P, Garepalli S (2011) Sonographic assessment of lower uterine segment at term in women with previous cesarean delivery. Arch Gynecol Obstet 283(3):455–459CrossRefGoogle Scholar
  28. 28.
    Buhimschi CS, Buhimschi IA, Yu C, Wang H, Sharer DJ, Diamond MP et al (2006) The effect of dystocia and previous cesarean uterine scar on the tensile properties of the lower uterine segment. Am J Obstet Gynecol 194(3):873–883CrossRefGoogle Scholar
  29. 29.
    Indraccolo U, Scutiero G, Matteo M, Mastricci AL, Barone I, Greco P (2015) Correlations between sonographically measured and actual incision site thickness of lower uterine segment after repeated caesarean section. Minerva Ginecol 67(3):225–229Google Scholar
  30. 30.
    Fiocchi F, Nocetti L, Siopis E, Currà S, Costi T, Ligabue G et al (2012) In vivo 3 T MR diffusion tensor imaging for detection of the fibre architecture of the human uterus: a feasibility and quantitative study. Br J Radiol 85(1019):e1009–e1017CrossRefGoogle Scholar
  31. 31.
    Fiocchi F, Petrella E, Nocetti L, Currà S, Ligabue G, Costi T et al (2015) Transvaginal ultrasound assessment of uterine scar after previous caesarean section: comparison with 3 T-magnetic resonance diffusion tensor imaging. Radiol Med (Torino) 120(2):228–238CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of ObstetricsUniversity of LeipzigLeipzigGermany
  2. 2.Department of RadiologyUniversity of LeipzigLeipzigGermany
  3. 3.Department of RadiologyUniversity of Leipzig-Heart CenterLeipzigGermany

Personalised recommendations