Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure

I P M Jordans, R A de Leeuw, S I Stegwee, N N Amso, P N Barri-Soldevila, T van den Bosch, T Bourne, H A M Brölmann, O Donnez, M Dueholm, W J K Hehenkamp, N Jastrow, D Jurkovic, R Mashiach, O Naji, I Streuli, D Timmerman, L F van der Voet, J A F Huirne, I P M Jordans, R A de Leeuw, S I Stegwee, N N Amso, P N Barri-Soldevila, T van den Bosch, T Bourne, H A M Brölmann, O Donnez, M Dueholm, W J K Hehenkamp, N Jastrow, D Jurkovic, R Mashiach, O Naji, I Streuli, D Timmerman, L F van der Voet, J A F Huirne

Abstract

Objective: To generate guidance for detailed uterine niche evaluation by ultrasonography in the non-pregnant woman, using a modified Delphi procedure amongst European experts.

Methods: Twenty gynecological experts were approached through their membership of the European Niche Taskforce. All experts were physicians with extensive experience in niche evaluation in clinical practice and/or authors of niche publications. By means of a modified Delphi procedure, relevant items for niche measurement were determined based on the results of a literature search and recommendations of a focus group of six Dutch experts. It was predetermined that at least three Delphi rounds would be performed (two online questionnaires completed by the expert panel and one group meeting). For it to be declared that consensus had been reached, a consensus rate for each item of at least 70% was predefined.

Results: Fifteen experts participated in the Delphi procedure. Consensus was reached for all 42 items on niche evaluation, including definitions, relevance, method of measurement and tips for visualization of the niche. A niche was defined as an indentation at the site of a Cesarean section with a depth of at least 2 mm. Basic measurements, including niche length and depth, residual and adjacent myometrial thickness in the sagittal plane, and niche width in the transverse plane, were considered to be essential. If present, branches should be reported and additional measurements should be made. The use of gel or saline contrast sonography was preferred over standard transvaginal sonography but was not considered mandatory if intrauterine fluid was present. Variation in pressure generated by the transvaginal probe can facilitate imaging, and Doppler imaging can be used to differentiate between a niche and other uterine abnormalities, but neither was considered mandatory.

Conclusion: Consensus between niche experts was achieved regarding ultrasonographic niche evaluation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: Cesarean section; Delphi technique; cicatrix; ultrasonography.

© 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Figures

Figure 1
Figure 1
Study design: stepwise modified Delphi method used to reach consensus on uterine niche definition and sonographic evaluation.
Figure 2
Figure 2
Flow diagram summarizing agreement with or rejection of items during Delphi procedure. Items were accepted if consensus agreement of at least 70% was reached.
Figure 3
Figure 3
Main niche and vesicovaginal fold. (a) Red and green areas represent main niche and blue area represents branch. (b) Green line indicates plica vesicouterina or uterovesical fold, while red line indicates vesicovaginal fold.
Figure 4
Figure 4
Position of calipers for different sonographic measurements of uterine niche in the sagittal plane.
Figure 5
Figure 5
Position of calipers for sonographic measurement of width of uterine niche in transverse plane. Both largest width and width at niche base should be measured.

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