Abdominopelvic ultrasonographic findings after uncomplicated delivery

Emergent postpartum pelvic sonography

This article describes the variable appearance of the normal postpartum uterus and reviews complications which can occur in the postpartum period, with particular emphasis on the sonographic findings. Postpartum complications are a common presentation to the emergency department. The majority of these patients present with secondary postpartum hemorrhage. Additional symptoms of pain or clinical findings of pyrexia and leukocytosis confound the clinical scenario and necessitate further evaluation with imaging. Ultrasonography is the mainstay in the initial imaging evaluation of the postpartum patient, with occasional progression to CT, MR, or angiography. We sought to provide a brief review of the literature, with pictorial review of key imaging findings, with a focus on ultrasonography. We provide a pictorial and brief literature review, with case examples from our institution, of key postpartum complications. Ultrasonography is an important component of evaluation in postpartum patients, particularly those with hemorrhage or other complication.

Ultrasound evaluation of the uterus in the uncomplicated postpartum period: a systematic review

OBJECTIVE

The aim of this systematic review and meta-analysis was to define the means and the upper limits of normal for endometrial thickness and uterine measurements in uncomplicated pregnancies at different postpartum periods.

DATA SOURCES

A search was conducted in the Medline, Embase, Cinahl, and Clinicaltrials.gov databases up to January 30, 2020.

STUDY ELIGIBILITY CRITERIA

We included studies reporting sonographic parameters of the uterus in the normal postpartum period.

METHODS

The continuous variables were expressed as means with standard deviations. The upper limits of normal were defined as the 95th percentile. Clinically significant differences in the uterine measurements between subgroups were defined as ≥2 cm; significant differences in the uterine volume were defined as >10%. The primary outcome was the endometrial thickness; others sonographic parameters that were analyzed were the uterine anteroposterior diameter, longitudinal diameter, width, and volume.

RESULTS

A total of 5260 articles were identified. Of these, 80 were assessed for their eligibility for inclusion and 32 studies were included in this systematic review. These studies included 3106 women (55% multiparas and 82% with vaginal deliveries) who underwent transabdominal and/or transvaginal ultrasound from the first postpartum day to a maximum of 6 weeks postpartum. The upper limit of normal (95th percentile) for the endometrial thickness was 25 mm by 7 days postpartum and this continued to decrease (18 mm at 14 days, 12 mm at 4 weeks, and 9 mm at 6 weeks) in a similar manner for all the women regardless of parity or mode of delivery. All the other uterine measurements also gradually decreased during the puerperium for all the women regardless of parity or mode of delivery.

CONCLUSION

These upper limits of normal for the postpartum endometrium and uterine measurements in uncomplicated pregnancies provide clinical guidance for the sonographic evaluation of women with complicated postpartum courses.

Risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section: a prospective study

Introduction: Post-partum hemorrhage is a major cause of maternal mortality. Ultrasonography is a safe, rapid, and noninvasive diagnostic tool which can be used to identify and measure the abdomino-pelvic free fluid in post-partum period.Objective: This study was conducted to evaluate the risk factors and clinical significance of abdomino-pelvic free fluid after cesarean section.Method: Demographic data, indication of cesarean section, duration of operation, volume of intraoperative blood loss, and instability in vital signs, blood transfusion, decreased Hb level, and decreased urine output were documented in 100 women with cesarean delivery 4 and 24 h after surgery. Abdomino-pelvic free fluid volume was estimated by ultrasound study.Result: Four hours after cesarean, minimal, moderate, and large amount of free fluid was seen in 38(38%), 45(45%), and 17(17%) patients respectively. The volume of free fluid was decreased generally as 73 (73%) of patients had minimal amount of free fluid 24 h after surgery. There was statistically significant relationship between volume of blood loss during cesarean and the volume of free fluid 4 h (and not 24 h) after surgery. There was no statistically significant relationship between duration of operation and the volume of free fluid 4 and 24 h after cesarean. There is statistically significant relationship between free fluid volume 4 h after surgery and hemodynamic instability.Conclusion: Ultrasonography detects even minimal amount of free fluid in post-cesarean patients but cannot predict their clinical course.

Comparison of postpartum sonographic findings after uneventful vaginal and cesarean section deliveries

Objective: To prospectively determine the sonographic findings of the postpartum uterus 24 hours after vaginal delivery and cesarean section. Methods: Women who had uneventful vaginal delivery or cesarean section from July 2015 to May 2018 in a tertiary care hospital were prospectively included. Uterine lengths, endometrium, amout of free fluid, the distance between the uterine fundus-promontorium and uterine fundus-L5 were evaluated 24 hours after delivery. Results: The mean (min-max) endometrial thickness in the vaginal delivery and cesarean section groups were 13.3 (4-25) and 12.4 (4-29) mm, respectively. Fundus-cervix length was significantly higher in the vaginal delivery group compared to the cesarean section group (184.05 ± 16.8 vs 163.6 ± 6.7 mm, p <0.001). The measurements of anterior and anterior-posterior walls of the uterus, anteroposterior uterine length and uterine width were similar in both groups. Promontorium-fundus length was significantly higher in patients who delivered vaginally than those by cesarean section (123.3 ± 13.6 vs 108.7 ± 23.3 mm, p = 0.005). Conclusion: The measurement of L5-fundus distance is a simple and effective technique to evaluate the size of the uterus. Homogenous endometrium up to 30 mm in asymptomatic patients may be a normal finding 24 hours after delivery. The results of this study may be helpful in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability.

Objective: To prospectively determine the sonographic findings of the postpartum uterus 24 hours after vaginal delivery and cesarean section. Methods: Women who had uneventful vaginal delivery or cesarean section from July 2015 to May 2018 in a tertiary care hospital were prospectively included. Uterine lengths, endometrium, amout of free fluid, the distance between the uterine fundus-promontorium and uterine fundus-L5 were evaluated 24 hours after delivery. Results: The mean (min–max) endometrial thickness in the vaginal delivery and cesarean section groups were 13.3 (4–25) and 12.4 (4–29) mm, respectively. Fundus-cervix length was significantly higher in the vaginal delivery group compared to the cesarean section group (184.05 ± 16.8 vs 163.6 ± 6.7 mm, p <0.001). The measurements of anterior and anterior-posterior walls of the uterus, anteroposterior uterine length and uterine width were similar in both groups. Promontorium-fundus length was significantly higher in patients who delivered vaginally than those by cesarean section (123.3 ± 13.6 vs 108.7 ± 23.3 mm, p = 0.005). Conclusion: The measurement of L5-fundus distance is a simple and effective technique to evaluate the size of the uterus. Homogenous endometrium up to 30 mm in asymptomatic patients may be a normal finding 24 hours after delivery. The results of this study may be helpful in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability.