International Journal of Gynecology and Obstetrics 114 (2011) 234237

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

2D versus 3D transabdominal sonography for the measurement of lower uterine

segment thickness in women with previous cesarean delivery
Vincent Y.T. Cheung a,, Fang Yang a, Kwok-Yin Leung a, b
a
b

Department of Obstetrics and Gynecology, Queen Mary Hospital, University of Hong Kong, Hong Kong
Department of Obstetrics and Gynecology, Queen Elizabeth Hospital, Hong Kong

a r t i c l e

i n f o

Article history:
Received 12 November 2010
Received in revised form 3 March 2011
Accepted 26 May 2011
Keywords:
Lower uterine segment thickness
Previous cesarean section
2D Ultrasound
3D ultrasound

a b s t r a c t
Objective: To evaluate the intermethod reliability of using 3D versus 2D transabdominal sonography in the
measurement of lower uterine segment (LUS) thickness in women with previous cesarean delivery, in
addition to determining the interobserver reliability of 2D and 3D transabdominal sonography in LUS
measurement. Methods: Between February and July 2010 at Queen Mary Hospital, Hong Kong, 40 pregnant
women with a history of previous cesarean delivery at 3639 weeks of pregnancy underwent LUS
measurement via 2D and 3D transabdominal sonography by 2 observers. The 3D examination was performed
on the multiplanar display of the longitudinally acquired LUS volume. Inner myometrial thickness (MT) and
full thickness (FT) were measured at the thinnest portion and perpendicular to the contour of the LUS. Results:
The 2D and 3D LUS measurements obtained by the 2 observers were comparable (intraclass correlation
coefcient [ICC]: MT, 0.81 and 0.98, respectively; FT, 0.76 and 0.98, respectively). For transabdominal LUS
measurement, 2D MT provided the best interobserver reliability (ICC: 2D MT, 0.95; 2D FT, 0.91; 3D MT, 0.82;
3D FT, 0.77). Conclusion: Compared with the 2D approach, 3D transabdominal sonography does not seem to
improve the reliability of LUS measurement. 2D measurement of MT seems to be most reliable between
different observers.
2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Uterine rupture is an uncommon complication of vaginal birth after
cesarean (VBAC), the maternal and fetal consequences of which can be
serious and potentially life threatening [14]. At present, there are no
reliable methods for predicting the risk of uterine rupture in women
attempting VBAC. Some authors have suggested that sonographic
measurement of the lower uterine segment (LUS) may help to select
women with the lowest risk of uterine rupture during labor [58].
Although it has been shown that the risk of a scar defect is inversely
correlated with LUS thickness, the techniques of this measurement
remain controversial [68]. In a recent systemic review of 12 studies
involving 1834 women, Jastrow et al. [8] conrmed that women
with uterine defects had thinner LUS than those without defects. Of the
12 studies included in the review, 7 measured the full LUS thickness,
4 measured the myometrial layer only, and 1 measured both. However,
owing to the heterogeneity of the studies, no ideal cut-off for lower
uterine thickness could be recommended for clinical purposes, and the
optimal cut-off value varied from 2.0 to 3.5 mm for the full LUS thickness
and from 1.4 to 2.0 mm for the myometrial layer [8].

Corresponding author at: Department of Obstetrics and Gynecology, Queen Mary

Hospital, 102 Pokfulam Road, Hong Kong. Tel.: + 852 22553914; fax: + 852 25173278.
E-mail address: vytc@hku.hk (V.Y.T. Cheung).

In late pregnancy, the LUS appears sonographically as a 2-layered

structure comprising the echogenic muscularis and mucosa of the
bladder wall, including part of the visceralparietal peritoneum, and
the relatively hypoechoic myometrial layer. The chorioamniotic
membrane and the decidualized endometrial layer cannot usually
be seen separate from the myometrium [5,6]. In vertex-presenting
fetuses, the presenting part may be rmly applied against the LUS
with no amniotic uid visible between these 2 structures. Various
techniques have been used to measure the LUS, including transabdominal (TA) and transvaginal approaches. In some studies [5,9,10],
the entire full LUS thickness was measured, whereas only the inner
myometrial layer was included in the measurement in other studies
[6,11,12]. However, almost all studies reported up-to-date use of 2D
sonography in measuring the LUS.
The introduction of 3D volume sonography has enabled multiplanar
display of 3D images of the LUS, which potentially can improve the
reliability of LUS measurement. One of the best uses of 3D ultrasound is
in nding the true center of an object of interest; thus, it could
theoretically locate the thinnest area in the LUS. Intermethod and
interobserver reliability are important when evaluating a clinical test
because they ensure reliable measurements when made via another
technique or observer, respectively. Previously, only 1 study addressed
the reliability of LUS measurement using 2D and 3D approaches [13].
However, that study did not assess the intermethod reliability of LUS
measurement using 3D sonography compared with the 2D approach.

0020-7292/$ see front matter 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2011.03.021

V.Y.T. Cheung et al. / International Journal of Gynecology and Obstetrics 114 (2011) 234237

The objective of the present study was to evaluate the intermethod

and interobserver reliability of 2D versus 3D TA sonography for
LUS measurement.

2. Materials and methods

The present prospective cohort study included 40 pregnant
women who were admitted to Queen Mary Hospital, Hong Kong, for
elective cesarean delivery between February and July 2010. All
women were between 37 and 39 completed weeks of pregnancy
and had undergone 1 previous cesarean delivery. None of the women
were in labor at the time of ultrasound examination. Women with
multiple gestation, abnormal amniotic uid volume, or placenta
previa were excluded from the study. Written informed consent was
obtained from the participants. The study was approved by the
Institutional Review Board of the University of Hong Kong and the
Hospital Authority Hong Kong West Cluster.
All sonographic examinations were performed with an ultrasound
machine (Voluson 730 Pro; GE Medical Systems, Milwakee, WI, USA)
equipped with a 48-MHz transducer for 2D and 3D volume scanning.
Measurements were performed by 2 sonographers, Observer A (VYTC)
and Observer B (YF).
The 2D and 3D LUS thickness measurements were obtained using a
TA approach. The 2D TA LUS thickness was measured using a
previously described technique [6]. The technique was performed
with a full urinary bladder to enable good imaging of the LUS, which
was examined longitudinally and transversely to identify any areas of
obvious dehiscence or rupture. The thinnest zone of the LUS was
identied visually. The area was magnied at least to the extent that
any movement of the caliper would produce a change in measurement of not more than 0.1 mm. Both the inner myometrial thickness
(MT; with the measuring caliper placed at the urinary bladder wall
myometrium interface and the myometrial/chorioamniotic membrane
amniotic uid interface) and the full thickness (FT; with the measuring
caliper placed at the urinebladder wall interface and the myometrial/
chorioamniotic membraneamniotic uid interface) were measured
(Fig. 1). At least 3 measurements were made for each thickness, with the
lowest value taken as the LUS measurement. The numeric display was
covered during the examination to avoid bias when performing the 3D
measurement.

235

After 2D examination, a 3D volume of the LUS was acquired

longitudinally. Each observer manipulated their own acquired
volumes on the multiplanar display and searched for the thinnest
portion of the LUS (Fig. 2). Both the MT and the FT were measured,
perpendicular to the contour of the LUS, as described for the 2D
examination. The observers were blinded to the measurements by a
label covering the numeric display. The 2 observers were not aware of
each other's measurements.
Interobserver reliability, corresponding to the agreement between
2 measurements made using the same method by 2 different
observers, and intermethod reliability, for comparison of measurements made via 2D and 3D approaches, were assessed via intraclass
correlation coefcient (ICC). For each method, the agreement
between the thinnest measurements of the observers was checked
using the BlandAltman method for limits of agreement. The cut-off
values of 1.5 mm for MT, and 2.3 mm and 3.5 mm for FT (which have
been reported as best predicting the risk of uterine rupture [57])
were also used to assess interobserver and intermethod reliability,
quantied with the coefcient. The strength of the coefcient was
judged according to the criteria proposed by Cohen: less than 0.41
was considered poor; 0.410.60 was moderate; 0.610.80 was good;
and 0.811.0 was excellent [14].
It was estimated that a sample size of 34 women would be
required to compare the difference in mean LUS thickness between
different observers and methods, for an of 0.05 and a power of 0.80,
with an anticipated difference in the mean LUS thickness of 0.4 mm
and an anticipated SD of 0.8 mm [13,15]. Statistical analysis was
performed using SPSS 16.0 (SPSS, Chicago, IL, USA) and GraphPad
4.0 (GraphPad, La Jolla, CA, USA).
3. Results
The mean age of the study population was 34.4 3.4 years, mean
body weight was 69.1 14.4 kg, and mean gestational age at
sonographic examination was 38.2 0.9 weeks. The mean LUS
thicknesses measured by Observer A were 1.86 1.33 mm, 3.61
1.51 mm, 2.04 1.11 mm, and 4.16 1.37 mm for 2D MT, 2D FT, 3D
MT, and 3D FT, respectively. The corresponding measurements
obtained by Observer B were 1.96 1.34 mm, 3.82 1.68 mm, 1.97
1.31 mm, and 3.87 1.68 mm, respectively.
With regard to intermethod reliability, both the MT and the FT
measurements obtained via 3D sonography were comparable to those
obtained with the 2D approach (Table 1). However, Observer A
seemed to have lower ICC on both comparisons. The coefcients
were generally good for Observer B, irrespective of the cut-off values
used, whereas Observer A obtained good correlation only when using
the cut-off MT measurement of 1.5 mm.
All techniques for TA LUS measurement showed good agreement
between observers (Table 2), although 2D MT measurements were
associated with the best interobserver reliabilitywith an ICC of 0.95
compared with ICCs of 0.770.91 for other approaches. Thus, measuring
LUS MT resulted in the narrowest 95% limits of agreement (Fig. 3). Also,
the best interobserver reliability was achieved with a cut-off value of
1.5 mm (MT) obtained using the 2D approach (Table 2).
4. Discussion

Fig. 1. 2D transabdominal longitudinal sonogram of the lower uterine segment showing

measurements of inner myometrial thickness (arrows) and full thickness (arrowheads). B, urinary bladder; H, fetal head.

The ndings of the present study indicate that, compared with

the 2D approach, 3D TA sonography does not seem to improve the
interobserver reliability of LUS measurement. More specically, the
best interobserver reliability was obtained by measuring only the
inner MT of the LUS using 2D sonography. At present, LUS-measuring
techniques and the cut-off values used to predict uterine rupture are
still controversial. One major concern regarding LUS thickness
measurement is the intermethod reliability. Jastrow et al. [15]
reported good correlation between observers regarding full LUS

236

V.Y.T. Cheung et al. / International Journal of Gynecology and Obstetrics 114 (2011) 234237

Fig. 2. Multiplanar images of the lower uterine segment obtained from 3D transabdominal sonography.

thickness using both TA and transvaginal approaches. However, very

few studies have evaluated the intermethod reliability of myometrial
layer measurement.
We believe that 3D sonography can be of potential clinical value in
the management of women with previous cesarean delivery. Multiplanar display of 3D images enables simultaneous longitudinal,
transverse, and coronal views, which allows measurements in a
plane perpendicular to the contour of the LUS. This also enables a
thorough and complete examination of the entire LUS, which is
particularly useful when assessing the risk of uterine rupture in
women with unknown previous cesarean scar. In addition, the time
taken to acquire 3D volume is much shorter than that needed to
acquire all 2D planes for the same measurement; thus, LUS
measurement via 3D sonography could help beginners to learn the
measuring techniques.
The use of 3D sonography for LUS measurement was rst studied by
Martins et al. [13], who reported that the technique signicantly
improved the reliability of transvaginal measurement of LUS muscular
thickness. However, that study evaluated only the intraobserver and

interobsever, but not the intermethod, reliability of the 2D and 3D

measurements [13]. To gain initial experience in the use of 3D
sonography for LUS measurement, the authors use only the TA approach
to measure both the FT and the inner myometrial layer. In the present
study, using 3D TA sonography did not seem to improve the accuracy or
reliability of LUS measurement compared with the 2D approach;
although there was good agreement among all measurementswith
ICCs of more than 0.75measuring the inner MT using the 2D approach
provided the best interobserver reliability. One possible explanation for
this nding is that the observers were more familiar with inner
myometrial layer measurement because measurement of this layer,
rather than the FT, to predict uterine rupture was advocated by the
principal author, as reported in his rst series of cases [16]. In terms of
limitations, the present study could have been biased toward greater
reliability because all of the ultrasound examinations were performed
by only 2 sonographers. Additional studies to evaluate the potential
reasonssuch as differences in resolution and inuence of movement
artifactsjustifying the discrepancy of the 2D versus the 3D measurements would be worthwhile.

Table 1
Intermethod reliability for 2D and 3D LUS measurements.a

Table 2
Interobserver reliability for different LUS measurements.

Observer A

Absolute difference, mm
Intraclass correlation
coefcient
coefcient
1.5-mm cut-off (MT)
2.3-mm cut-off (FT)
3.5-mm cut-off (FT)

2D

Observer B

MT

FT

MT

FT

0.53 0.54
0.81

0.85 0.58
0.76

0.24 0.16
0.98

0.25 0.25
0.98

0.67

0.35
0.33

0.74

0.63
0.82

Abbreviations: FT, full thickness; LUS, lower uterine segment MT, myometrial thickness.
a
Values are given as mean SD unless otherwise indicated.

Absolute difference, mm
Intraclass correlation
coefcient
coefcient
1.5-mm cut-off (MT)
2.3-mm cut-off (FT)
3.5-mm cut-off (FT)

3D

MT

FT

MT

FT

0.32 0.27
0.95

0.55 0.44
0.91

0.51 0.53
0.82

0.79 0.68
0.77

0.88

0.63
0.37

0.65

0.08
0.29

Abbreviations: FT, full thickness; LUS, lower uterine segment MT, myometrial thickness.
a
Values are given as mean SD unless otherwise indicated.

V.Y.T. Cheung et al. / International Journal of Gynecology and Obstetrics 114 (2011) 234237

10

Mean LUS measurements (2D MT, mm)

2
1.5
1
0.5
0
-0.5

-1
-1.5

-2

10

12

Mean LUS measurements (2D FT, mm)

2
1.5
1
0.5
0
-0.5
-1
-1.5
-2
-2.5
-3
0

Mean LUS measurements (3D MT, mm)

Difference between observers (mm)

Difference between observers (mm)

1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1

Difference between observers (mm)

Difference betweeen observers (mm)

237

3
2
1
0
-1

-2
-3

-4

10

Mean LUS measurements (3D FT, mm)

Fig. 3. BlandAltman plots showing interobserver differences in measurement of lower uterine segment (LUS) thickness. (a) 2D MT; (b) 2D FT; (c) 3D MT; (d) 3D FT. Abbreviations:
FT, full thickness; MT, inner myometrial thickness.

The present study did not clearly demonstrate the benets of using
3D over 2D sonography for LUS measurement. However, whether the
use of the transvaginal 3D approach can improve the reliability of LUS
measurement is a potential area for future research.
Conict of interest
The authors have no conicts of interest.
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