Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus.

To assess whether level of agreement among experts in distinguishing between septate and normal/arcuate uterus using subjective judgments from review of coronal view from three-dimensional ultrasound. We also aim to determine the inter-observer reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using the most voted option by experts (CUME - Congenital Uterine Malformation by Experts) as a reference standard. Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and submitted to 15 experts (5 clinicians, 5 surgeons and 5 sonologists). They were instructed to vote between normal/arcuate (normal uterine morphology or degree of distortion caused by the internal indentation is not clinically relevant) or septate uterus (the degree of distortion caused by the internal indentation is clinically relevant). Two other raters independently measured indentation depth, indentation angle and indentation to wall thickness (I:WT) ratio. The agreement among experts was assessed by kappa, the inter-rater reliability was assessed by concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed by the area under ROC curve (AUROC) and the best cut-off value was assessed using Youden's index, considering the most voted option (CUME) as the reference standard. There was a good agreement among the impression of all experts (kappa = 0.62). There were 18 septate and 82 normal/arcuate uteri by CUME; ESHRE-ESGE criteria (I:WT ratio > 50%) resulted in 80 septate and 20 normal/arcuate, while ASRM criteria resulted in 5 septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uterus would not be classified (gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa = 0.10); the agreement between ASRM criteria for septate and CUME was 87% (kappa = 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa = 0.93). Among the three measurements, the inter-rater reproducibility of indentation depth (CCC=0.99, 95%CI=0.98-0.99) was better than both indentation angle (CCC=0.96, 95%CI=0.94-0.97) and I:WT ratio (CCC=0.92, 95%CI=0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good: AUROC between 0.96 and 1.00. The best cut-off values for these measurements were: indentation depth ≥ 10 mm, indentation angle < 140°, and I:WT ratio > 110% . The suggested cut-off value by ESHRE-ESGE overestimates the prevalence of septate uterus while those by ASRM underestimate this prevalence, leaving in the gray zone most of the uteri considered as being septate by experts. We recommend considering indentation depth ≥ 10 mm as septate, since it is simple, reliable and in agreement with the opinion of experts. This article is protected by copyright. All rights reserved.

Citation

Artur Ludwin, Wellington P Martins, Carolina O Nastri, Inga Ludwin, Marcela A Coelho Neto, Valeria M Leitão, Maribel Acién, Juan L Alcazar, Beryl Benacerraf, George Condous, Rudy-Leon De Wilde, Mark Hans Emanuel, William Gibbons, Stefano Guerriero, William W Hurd, Deborah Levine, Steven Lindheim, Antonio Pellicer, Felice Petraglia, Ertan Saridogan. Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2017 Oct 11

PMID: 29024135

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