Verbessert die Diagnostik des unteren Uterinsegments die Geburtsplanung bei Status nach Sectio?

Zusammenfassung

Einleitung Bei Patientinnen mit Status nach Sectio ist die sonografische Diagnostik des unteren Uterinsegments (uUS) weit verbreitet. Ihr Nutzen für die Geburtsplanung ist jedoch nicht ausreichend belegt. Es gibt weder ein einheitliches Untersuchungsprotokoll noch einen sicheren Cut-off-Wert. Ziel dieser Studie war es, den Wert der uUS-Diagnostik in der klinischen Routine zu prüfen.

Material und Methoden In die retrospektive Analyse wurden 631 Patientinnen mit Status nach Sectio eingeschlossen. Bei 399 (63%) Patientinnen war eine sonografische Dickenmessung des Myometriums (muUS) und/oder des gesamten uUS (guUS)) erfolgt. Die Inzidenz von Uterusdefekten sowie der Zeitpunkt und die Modalität ihrer Diagnostik wurden eruiert. Sensitivitäten, Spezifitäten, positive (PPV) und negative prädiktive Werte (NPV) wurden für verschiedene Cut-offs errechnet.

Ergebnisse Uterusdefekte traten bei 28 (4,4%) Patientinnen auf. Die Detektionsrate für die Sonografie war gering (13,6%), die Sensitivität/ Spezifität/ PPV/ NPV für niedrigere Cut-off-Werte (2 mm (guUS)/ 1 mm (muUS): 75/96/48,3/98,7%) jedoch besser als für höhere (3 mm (guUS)/ 2 mm (muUS): 15,8/93,2/10,4/68,7%).

Diskussion Der Nutzen der sonografischen uUS-Diagnostik erscheint überschätzt. Da ihre Genauigkeit von zahlreichen methodischen Faktoren beeinflusst wird, könnte sie durch ein einheitliches Protokoll mit einem transabdominellen und transvaginalen Scan durch einen erfahrenen Untersucher verbessert werden. Ein geeigneteres Untersuchungsziel für die Selektion nach Sectio könnte der Ausschluss von Uterusdefekten sein.

Abstract

Introduction Lower uterine segment (LUS) thickness measurement is frequently used to select patients for trial of labor after a previous cesarean section (TOLAC). To date no significant benefit of LUS measurement has ever been proven, and no standard protocol or clear cut-off value exists. The aim of this study was to evaluate the benefit of LUS measurement in a daily routine setting.

Material and Methods In this retrospective study, we evaluated 631 pregnancies after previous cesarean section (CS). Ultrasound measurements of myometrial (mLUS) and/or full LUS (fLUS) thickness were performed in 399 (63%) patients. The incidence, time, and mode of detection of uterine defects were studied. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for different cut-off values of LUS thickness.

Results Uterine defects were diagnosed in 28 (4.4%) patients. Detection rate of ultrasound was low (13.6%), with better sensitivity, specificity, PPV, and NPV at lower (2 mm (fLUS) / 1 mm (mLUS): 75/96/48.3/98.7%) than at higher cut-off values (3 mm (fLUS) / 2 mm (mLUS): 15.8/93.2/10.4/68.7%).

Discussion The benefit of LUS thickness measurement appears overestimated. As a large number of methodological factors trigger inaccuracy, a consistent protocol including both a transabdominal and a transvaginal scan performed by a trained examiner might improve accuracy. Exclusion of uterine defects might be more useful for prenatal selection after CS.

Schlüsselwörter

Kaiserschnitt - Schwangerschaft - Ultraschall - Uterus - unteres Uterinsegment

Key words

caesarean section - pregnancy - ultrasound - uterus - lower uterine segment

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