Facts, Views & Vision
in ObGyn

Journal of the European Society for Gynaecological Endoscopy

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Structured hysteroscopic examination of uterine niches: a modified Delphi procedure

N. Min1,2, R. A. de Leeuw1,2, L.F. van der Voet3, A. Di Spiezio Sardo4, P.N. Barri-Soldevila5, M. Dueholm6, O. Donnez7, E. Saridogan8, T.J. Clark9, H.A.M. Brolmann1, A.L. Thurkow1, D. Jurkovic10, T. van den Bosch11, T. Bourne12, W.J.K. Hehenkamp1, J.A.F. Huirne1,2, for the ESGE Uterine Niche Working Group

1 Amsterdam University Medical Center, location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, The Netherlands
2 Amsterdam Reproduction and Development research institute, Amsterdam, The Netherlands
3 Deventer Ziekenhuis, Obstetrics and Gynaecology, Deventer, The Netherlands
4 Università degli Studi di Napoli “Federico II”, Obstetrics and Gynaecology, Napoli, Italy
5 Institut Universitari Dexeus- Càtedra d’Investigació en Ginecologia-, Departament d’Obstetricia i Ginecologia-, Barcelona, Spain
6 Aarhus University, Department of Clinical Medicine - Department of Obstetrics and Gynaecology, Aarhus, Denmark
7 Complex endometriosis center, Polyclinique Urbain V (Elsan group), Avignon, France
8 University College London Hospitals, Reproductive Medicine and Minimal Access Surgery Units, London, United Kingdom
9 Birmingham Women’s & Children’s Hospital, University of Birmingham, Birmingham, United Kingdom
10 University College Hospital, Gynaecology Diagnostic and Outpatient Treatment Unit, London, United Kingdom
11 Universitair Ziekenhuis Leuven, Department Gynaecology and Obstetrics, Leuven, Belgium
12 Queen Charlotte’s and Chelsea Hospital, Imperial College London, London, United Kingdom.

Keywords:

Delphi technique, caesarean scar defect, uterine niche, hysteroscopy, diagnostic imaging, classification


Published online: Sep 30 2024

https://doi.org/10.52054/FVVO.16.3.036

Abstract

Background: Uterine niches in the Caesarean section scar are seen in approximately half of women with a history of caesarean delivery. Whilst a structured ultrasound assessment of caesarean defects has been described, there is no consensus on a structured hysteroscopic evaluation.

Objectives: To propose a methodology for a structured hysteroscopic evaluation of uterine niches.

Materials and Methods: We conducted a modified Delphi procedure, including two online rounds and two face-to-face meetings of the members of the ESGE Uterine Niches Working Group. The taskforce members have extensive experience in hysteroscopic niche evaluation. The consensus was predefined as a Rate of Agreement of at least 75%.

Results: Thirteen experts participated in this modified Delphi procedure. There was consensus on the need for a standardised methodology and the hysteroscopic definition of a niche as any indentation in the myometrium at the site of a previous CS. There was consensus that a hysteroscopic evaluation of a niche must be combined with ultrasound to measure the residual myometrial thickness. In addition, it was agreed that niches should be subclassified as ‘simple’, ‘simple with one branch’, or ‘complex’. There was consensus that the following items should be described during a hysteroscopic niche evaluation: the number of niches, the size in relation to the size of cervical canal, the presence of polyps, crypts, cysts, fibrotic tissue, blood, mucus, placental remnants, a dynamic valve, the appearance of the endometrium, the number of blood vessels and bleeding from blood vessels within the defect.

Conclusion: Using a modified Delphi procedure with international experts, consensus was achieved on the hysteroscopic evaluation and classification of niches in the uterine caesarean section scar.

What is new? A structured registration form was developed to aid consistency in hysteroscopic niche reporting.