Lancet ;1 Both are main causes of maternal death worldwide; therefore, a correct diagnosis is of paramount importance. Lancet ;1 The uterine involution has been previously evaluated with respect to the palpation of the uterine height, which can be difficult in obese women or in those with uterine myoma.
BMJ ;4 The uterus was one of the first organs to be examined by ultrasonography when ultrasound was introduced into the clinical practice by Donald and his collaborators. Lancet ;1 The high-resolution ultrasound equipment that is currently available increases the role of ultrasonography in assessing the normal and abnormal 3 3 Almeida CM.
Campinas: Universidade Estadual de Campinas; puerperal dynamics. Ultrasonography is a non-invasive, low-cost technique that is well accepted by patients. Rev Bras Ginecol Obstet ;23 03 Portuguese. Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery. Study of the uterine cavity by ultrasound in the early puerperium. Ultrasound assessment of puerperal uterine involution.
Ultrasonography of the uterus after normal vaginal delivery. Ultrasonic evaluation of the postpartum uterus in the management of postpartum bleeding. Realtime ultrasonographic analysis of the normal postpartum uterus: technique, variability, and measurements. J Ultrasound Med ;13 03 on uterine involution.
It is important to know the normal ultrasonographic involution of the uterus during the postpartum period to improve our ability to distinguish the pathological from the normal puerperium and thereby avoid unnecessary invasive procedures. Furthermore, the knowledge obtained from ultrasonographic examinations can help us better understand the physiology of the postpartum period.
The aim of this study was to describe the changes in the uterine dimensions using ultrasound in the early puerperium following cesarean section or vaginal birth among women delivering term singleton infants who experienced an uncomplicated postpartum period. A secondary objective was to assess the influence of parity, mode of delivery, breastfeeding and birth weight on uterine involution according to the time at which it was assessed.
All the subjects received and signed the free and informed consent form. The exclusion criteria were the presence of postpartum infections surgical wound or endometritis or placental remains. The patients underwent pelvic transvaginal and transabdominal ultrasound evaluations on days 1 D1 , 2 D2 and 7 D7 of the postpartum period.
The examinations included the assessment of: the longitudinal, anteroposterior and transverse uterine diameters; the uterine volume by the formula: longitudinal diameter LD X anteroposterior diameter APD X transverse diameter TD X 0.
The patients were asked whether they were breastfeeding. Birth weight, mode of delivery and parity were obtained from the obstetric records. All of the examinations were performed by a single researcher directly involved in the project.
Data were analyzed with the statistical analysis program S-Plus 8. The studied parameters underwent a descriptive analysis, and the results were expressed as the mean and standard deviation SD. Parametric and nonparametric mean comparison tests were used analysis of variance [ANOVA] and Spearman's rank correlation coefficient.
Ninety-one puerperal women underwent pelvic ultrasonographic examinations on D1 and D2, and 57 women also had an exam on D7 total of assessments. The mean age was 24 years range 13—41 years. Thirty-seven women were primiparous, 24 were secundiparous, and 30 had had 3 or more parturitions. The average number of children was 2. The exclusion criteria were as follows: preterm or multiple pregnancy, stillbirth, complicated postpartum bleeding intensive care measures were used, with B-Lynch suture after labour and uterine devascularisation , congenital uterine disorders bicornuate or unicornuate uterus, double uterus , uterine fibroids or oncological diseases, uterine scar, retained placental tissue, or endometritis postpartum.
Of the 46 women included in this study, 24 were primiparous group I and 22 multiparous group II. A serial ultrasonographic examination was carried out on the 1st, 3rd, 10th, 30th, 42nd, and 60th days of the postpartum period.
The first examination was performed within two hours after delivery. Each woman was examined 6 times, with the exception of 4 missed exams in group I and 2 exams in group II for personal reasons. An abdominal ultrasound scan was carried out on the the 1st, 3rd, and 10th days, while transvaginal sonoscopy was carried out, on the 30th, 42nd, and 60th days.
Uterine measurements were performed on the basis of commonly used recommendations for pelvic ultrasound and Doppler scans [ 15 — 22 ]. All the participants were provided with oral and written information about the study. The uterine length Figure 1 and the anteroposterior diameter AP Figure 2 were measured in longitudinal sections. This study compares both points of measurement in primiparous and multiparous patients.
The uterine width was measured in transverse section Figure 3 , the coronal view was evaluated on the 1st day to exclude congenital malformations of the uterus Figure 4.
The endometrial stripe thickness and the endometrial contents were evaluated in a longitudinal section. The uterine angle was measured in relationship with the longitudinal axis of the body Figure 5. The mean values of both left and right arteries were used Figure 6. All the analyses were performed using SPSS, version Continuous variables were summarized using descriptive statistics, including the number of subjects, mean, standard deviation, median, and confidence intervals with minimum and maximum values.
Categorical variables were expressed as numbers and percentages. The size of the uterus was measured by the length of the uterus, the uterine width, and the AP diameter. Almost all these parameters are dependent on parity. The uterus is slightly larger in multiparous women within two hours after childbirth and these indicators maintain higher values to the end of puerperium Table 2.
The size of the uterus decreases rapidly over the first 30 postpartum days 1st, 3rd, 10th, and 30th days ; later, the involution decreases steadily till two months postpartum. The trends of regression in the uterine dimensions the length, the width, and the AP diameter observed over two months after childbirth are similar in both groups Figures 7 and 8.
AP decreases following the same pattern as with other parameters of the uterus during the entire involution period in both points of both the groups Figures 9 and The 10th postpartum day is a special time for the uterine involution given the occurrence of dramatic changes in the uterine cavity during the normal puerperium experienced by both groups of women.
It is important to assess these changes in terms of uterine physiology. The differences found in the endometrial cavity changes over the uterus involution period between primiparous and multiparous subjects showed no statistically significant difference; however, the difference observed on the 10th postpartum day was statistically significant in primiparous women 9. The uterine angle deviation, in relation to the longitudinal axis of the body, changes from a particularly retroverted position to a more anteverted one.
The differences found between primiparous and multiparous women are not statistically significant, but the angle changes are likely to be increasingly larger during puerperium in multiparous women median difference from the first to the 60th day is The uterine artery flow examination and index RI measurements showed significant changes in both groups until midpuerperium.
The resistance RI of the uterine artery was low immediately after childbirth and showed a significant increase one month after parturition in both groups Figure 12 ; later, these changes tend to be more steady. The largest RI difference recorded in primiparous and multiparous women was within the first 10 postpartum days, while at the end of puerperium, no resistance differences were recorded Table 4.
Notching of the uterine artery Figure 13 undergoes changes during puerperium; however, the appearance of the diastolic notch is observed not in all women even after two postpartum months Figure Unfortunately, no relevant correlations were found. The uterine involution starts immediately after the delivery of placenta [ 24 ]. Understanding of normal view of the uterus during the entire period of puerperium helps practitioners to avoid unnecessary interventions for alleged retained products of conception RPOC or atonic uterus [ 6 — 8 , 16 ].
During the normal puerperium period, the uterine involution is defined by the changing indices of the uterine size, the uterine cavity inserts, and the uterine artery flow [ 1 — 5 , 15 ]. Until recently, there were no studies showing a view of the uterus immediately after childbirth. Most of the studies publish the first ultrasound examination findings on the 1st, 2nd, and 3rd postpartum days [ 1 , 4 , 11 — 13 ], but there is not a single ultrasound study examining the uterus within the first two hours after delivery.
The strengths of this study are as follows: the research, from the beginning to the end, was conducted by one person; the same person assisted the women under analysis during delivery; the first data are obtained from the earliest puerperium within two hours after delivery ; a detailed explanation of the differences observed between primiparous and multiparous women is provided. The information obtained from the findings of this study on the uterus view over this period is highly efficient in postpartum hemorrhage cases.
Nowadays, the doctor can bring a portable ultrasound machine to the delivery room and examine the uterus for RPOC. If we see no RPOC, we can use conservative measures for treatment without any interventions.
The knowledge acquired on the physiological differences occurring between primiparous and multiparous females over the puerperium period facilitates differentiating a normal uterine contraction from an inadequate one in case of atonic uterus [ 1 , 24 ]. The findings of this study showed that although the multiparous uterus shrinks more intensively [ 25 , 26 ], it still remains of a larger size from the very early till the late puerperium.
Most of the authors [ 1 — 5 ], except for one who represents the newest studies [ 9 ], show no correlation between the involution of the uterus and parity. This study shows the differences observed in the uterus size of primiparous and multiparous women. Statistically significant bigger AP and uterus width in multiparous than primiparous women were found within one month after childbirth. Other parameters revealed that the uterine size tends to be larger in the multiparous, yet no significant differences were found.
We recommend that AP is measured in the widest part of the longitudinal view of the uterus in the same way a nonpregnant uterus is measured [ 3 — 5 , 15 — 20 ]. This study is intended to draw attention to the 10th day, when the diagnosis of the retained products of conception RPOC could be made by mistake due to a special view of the uterine cavity.
All of the women involved in the study both groups complained of the increased vaginal bleeding on the 10th—14th postpartum days, especially after physical exertion or more frequent breastfeeding, and the ultrasound findings show mostly fluid insertion of the uterine cavity in both groups at this period. The same trend was found by other authors [ 1 , 4 , 5 ]; however, they did not find any correlation between the uterine cavity and parity.
Our study found statistically significant larger width of uterine cavity in multiparous women. Graphs showing the daily measurements and correlation coefficients were used to describe involution. The proportion of healthy women who would have been identified as healthy by the screening method was estimated its specificity. During every physical examination of your patient assess her physical activity and psychoemotional state.
Note the colour of the skin and mucus. Ask a patient about peculiarities of voiding and defecation. Assessment of uterine involution by palpation of the uterine fundus via the anterior abdominal wall.
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