Ultrasonographic evaluation of the postpartum uterus

Postpartum obstetric complications: a guide for radiologists

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

A 3D-printed condom intrauterine balloon tamponade: Design, prototyping, and technical validation

Post-partum haemorrhage is among the main causes of (preventable) mortality for women in low-resource settings (LRSs), where, in 2017, the mortality ratio was 462 out of every 100 000 live births, over 10 times higher than for high-resource settings. There are different treatments available for post-partum haemorrhage. The intrauterine balloon tamponade is a medical device that proved to be a simple and cost-effective approach. Currently, there are several balloon tamponades available, with different design and working principles. However, all these devices were designed for high-resource settings, presenting several aspects that could be inappropriate for many lower-income countries. This paper presents the results of a preclinical study aiming at informing the design, prototyping and validation of a 3D-printed intrauterine balloon tamponade concept, contributing towards the United Nation's Sustainable Development Goal 3: Good health and Well-being. Frugal engineering concepts and contextualised design techniques were applied throughout, to define the design requirements and specifications. The performance of the final prototype was validated against the requirements of the UK National Health System (NHS) technical guidelines and relevant literature, measuring the water leak and pressure drop over time, both open air and in a approximate uterus model. The resulting prototype is made up of six components, some of which are easy to retrieve, namely a water bottle, a silicone tube and an ordinary condom, while others can be manufactured locally using 3D printers, namely a modified bottle cap, a flow stopper and a valve for holding the condom in place. Validation testing bore promising results with no water or pressure leak open air, and minimal leaks in the approximate uterus model. This demonstrates that the 3D printed condom-based intrauterine balloon tamponade is performing well against the requirements and, when compared to the state of the art, it could be a more appropriate and more resilient solution to low-resource settings, as it bypasses the challenges in the supply of consumables and presents a greener option based on circular economy.

Sonographic Detection of Surgical Site Fluid Collections and Postoperative Maternal Morbidity Following Cesarean Section

INTRODUCTION

 Surgical site infection (SSI) is one of the most common complications after cesarean and causes much burden on the mother as well as the health care system. SSIs are defined as infections of a surgical site up to 30 days after surgery. Ultrasonography of the surgical site may be a helpful tool to detect its complication. With this background, the following study was planned to evaluate the clinical significance of sonographically detected fluid collections and post-operative maternal morbidity following cesarean section (CS) and identify risk factors associated with their formation.

METHODS

This prospective observational study was conducted at the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial Medical College, Meerut. A total of 1000 women, who had undergone CS were included. Sonographic examination of the cesarean site was done on the 3^rd or 4^th postoperative day to look for any fluid collection in the parities or pelvis. All cases were followed on the 8^th postoperative day and finally on the 30^th postoperative day to look for any SSIs i.e. surgical wound problems like wound infection, induration, and discharge from a surgical wound, or even wound dehiscence and postoperative morbidity.  Results: Out of the total cases (1000), abdominal wound fluid collection was noted in 490 (49%) women after CS. Thirty-two patients were lost to follow-up, so 458 patients were followed, of which collection was septated or loculated in 62 (13.6%) and diffused in 396 (86.5%). Out of 62 loculated and 396 diffused cases, 21 (33.87%) and 20 (5.05%) cases reported surgical site abdominal wound infection and needed resuturing, respectively and it was found to be highly significant (p<0.001).

CONCLUSION

Post-operative fluid collections are common after CS. But it is the pattern of the fluid collection that determines post-operative wound infection and morbidity. Thus ultrasound of the cesarean site may be an important tool to detect surgical site wound complications earlier and to decrease postoperative morbidity.

How to Reach the Best Ultrasound Performance in the Delivery Room

Ultrasonography is an instrument that is present in the maternal-fetal assessment throughout pregnancy and with widely documented benefits, but its use in intrapartum is becoming increasingly relevant. From the assessment of labor progression to the assessment of placental disorders, ultrasound can be used to correlate with physiological findings and physical examination, as its benefit in the delivery room cannot yet be proven. There are still few professionals with adequate training for its use in the delivery room and for the correct interpretation of data. Thus, this article aims to present a review of the entire applicability of ultrasound in the delivery room, considering the main stages of labor. There is still limited research in evidence-based medicine of its various possible uses in intrapartum, but it is expected that further studies can bring improvements in the quality of maternal and neonatal health during labor.

Imaging in Uterine Artery Pseudoaneurysm: A Rare, Potentially Fatal Cause of Secondary Post-partum Hemorrhage

Secondary postpartum hemorrhage is one of the important cause of postpartum morbidity and mortality. Uterine artery pseudoaneurysm is a rare, potentially fatal but treatable cause of secondary post-partum hemorrhage. If not diagnosed timely, it can lead to life-threatening hemorrhage. We report the case of a 41-year-old woman who presented with profuse vaginal bleeding on 32nd day of cesarean section. On imaging a left uterine artery pseudoaneurysm was found in the uterine wall with blood clots in the uterine cavity. Patient was managed with aggressive fluid resuscitation and immediate interventional radiology procedure of selective embolization of pseudoaneurysm. High index of suspicion is needed to search for rare vascular causes like pseudoaneurysm.

Pelvic ultrasonography of the postpartum uterus in patients presenting to the emergency room with vaginal bleeding and pelvic pain

Pelvic pain and vaginal bleeding are common symptoms in postpartum women presenting to the emergency room (ER). Pelvic ultrasonography plays a crucial role in evaluating symptomatic postpartum patients by allowing a rapid diagnosis and treatment initiation. The main goal of imaging is to distinguish between causes of pelvic pain and vaginal bleeding that may be managed conservatively and those requiring emergent intervention. This pictural essay focuses on the ultrasonographic features of common postpartum conditions for which patients may present to the ER with vaginal bleeding and pelvic pain, including retained products of conception, endometritis, uterine arteriovenous malformation, uterine artery pseudoaneurysm, ovarian vein thrombosis, bladder flap hematoma, and uterine dehiscence/rupture.

Managing patients with suspected postpartum retained products of conception using a novel sonographic classification

BACKGROUND

Suspicion of retained products of conception (RPOC) often arises after delivery and still poses a diagnostic and management challenge.

PURPOSE

To prospectively evaluate a sonographic classification for the management of patients with suspected RPOC after delivery.

MATERIAL AND METHODS

Based on grayscale and Doppler ultrasound parameters, patients were classified into high, moderate, or low probability of RPOC. For the low and moderate probability groups, an ultrasound follow-up at the end of the puerperium was recommended. For the high probability group, a follow-up examination was conducted 10-14 days after the first ultrasound, and patients with persistent high probability findings were referred for surgical intervention.

RESULTS

The sample was composed of 215 patients at risk of RPOC. Of these, 100, 93, and 22 patients were classified as having a low, moderate, or high probability of RPOC, respectively. Rates of RPOC were 55%, 2%, and 2% in the high, moderate, and low probability categories, respectively. When the categorization was based on the most recent ultrasound obtained during the puerperium, the adjusted RPOC prevalence rates were 71% in the high, 6% in the moderate, and 0% in the low probability groups.

CONCLUSION

This study confirms the effectiveness of our sonographic classification for managing patients with suspected RPOC after delivery. In all three categories, it is recommended to adhere to a conservative management protocol in clinically stable women until the end of the puerperium. This approach provides good predictability for RPOC and can reduce unnecessary surgical interventions.

The Importance of the Novel Postpartum Uterine Ultrasonographic Scale in Numerical Assessments of Uterine Involution Regarding Perinatal Maternal and Fetal Outcomes

Background: Uterine involution assessments are critical for the prevention of postpartum hemorrhage. Various methods have been used worldwide. Methods: The PUUS (Postpartum Uterine Ultrasonographic Scale) method evaluates, by transabdominal ultrasonography, the length of the endometrium of the uterine cavity occupied by blood or debris, from grade 0 (no blood) to grade 4 (over three-quarters of the endometrial length occupied by blood/debris). A total of 131 consecutive patients admitted for delivery in the Elena Doamna Obstetrics and Gynecology University Hospital in Iasi, Romania, were prospectively evaluated using the PUUS method. The mean age was 27.72 years old, and they were examined during the first 24–48 h after vaginal delivery, or in the first 48–72 h after cesarean delivery. For patients with a PUUS grade greater than 1, re-examination was preformed daily in the following days, until the PUUS grade decreased to 1 or 0. Results: By standardizing uterine involution in a numerical fashion, we precisely demonstrate that uterine involution varied with the method of delivery (vaginal/cesarean) and with the number of vials of oxytocin received intrapartum, but not with the number of vials of ergometrine maleate received, and not with the origin of the parturient (rural/urban).

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.

Ultrasound criteria for managing postpartum patients with suspicion of retention of conception products

Background

Retention of conception products is a common complication following delivery and remains a diagnostic and management challenge due to non-specific symptoms and ultrasound findings.

Purpose

To introduce a clinical approach for managing patients with suspected retained products of conception following delivery.

Material and Methods

The ultrasound examination included gray-scale and Doppler parameters which classified the patients into three groups: high, moderate, or low probability for retained products of conception. The same classification was used both to stratify individual risk for retained products of conception, as well as for counseling the appropriate management.

Results

The study included 66 patients. Retained products of conception was confirmed in 62%, 32% and 0% of the high, moderate and low probability groups, respectively. Additionally, each group was further divided according to the timing of the ultrasound examination: before or after 42 postpartum days. A significant increase, from 12% to 64%, in the positive predictive value was observed in the moderate probability group when the ultrasound was performed ≥ 42 days postpartum.

Conclusions

In the low probability group, no surgical intervention is recommended. When ultrasound findings are classified as high probability for retained products of conception, surgical evacuation of the uterine content is recommended. For clinically stable women with ultrasound findings consistent with moderate probability, ultrasound follow-up at the end of the puerperal period (42 days) is recommended. This approach may improve the sonographic prediction of retained products of conception and prevent unnecessary interventions.

Mechanical Properties of the Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) Device: In Vitro Tests

Objective  Postpartum hemorrhage (PPH) is the most common cause of maternal mortality and morbidity worldwide, most of which occurs in resource-poor settings. Placement of a uterine balloon may be life-saving in uncontrolled PPH. The Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) device is an ultra-low-cost uterine balloon designed for global access. The purpose of this study was to evaluate the mechanical properties of the ESM-UBT device. Study design  Intraluminal pressures, diameters, and burst volumes of condom uterine balloons and Foley catheter balloons of ESM-UBT devices were measured in open air and inside uterus models. Condom uterine balloons were tested with uterus model sizes of 100, 250, and 500mL. The condom-catheter O-ring attachment tensile strength was also evaluated. Results  All 28 samples of ESM-UBT condom uterine balloons maintained their integrity for at least 3 hours when subjected to pressures of 200 mm Hg or greater across each of the tested uterine volumes. No Foley catheter balloons burst after instillation of 30mL, O-rings withstood forces of 15.4 ± 2.1 N, and condom uterine balloons stretched to 35.8 ± 2.1 cm without loss of integrity. Conclusion  The mechanical properties of the ESM-UBT device make it attractive for scale across resource-poor settings.

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.

Physiological Uterine Involution in Primiparous and Multiparous Women: Ultrasound Study

PURPOSE

To examine the uterine involution period after uncomplicated delivery in primiparous and multiparous women.

METHODS

Longitudinal prospective study. Repeated parameters were measured and endometrial contents and diastolic notch were observed. Measurements of primiparous and multiparous women were carried out after labour on the 1st, 3rd, 10th, 30th, 42nd, and 60th postpartum days. The analysis was performed using SPSS version 21.

RESULTS

The median uterus parameters are bigger in multiparous group in physiological puerperium, but the decreasing trend is the same. The endometrial cavity on the 10th day was significantly wider in multiparous women and mainly echo-negative view of the uterine cavity was observed. The evaluation of the uterine angle deviation changes from an extremely retroverted position to a more anteverted position. RI of the uterine artery in both groups was low immediately after labour and significantly increased one month postpartum. Notching of the uterine artery undergoes changes, but diastolic notch does not appear in all postpartum women even after two months following labour.

CONCLUSIONS

The puerperium period after normal vaginal delivery depends on parity. The trend of involution in primiparous and multiparous women follows a similar pattern, yet, it lasts longer in the multiparous women. Ultrasound of uterine is certainly a useful tool after labour and may be important in facilitating an early detection of postpartum uterine complications.

Imaging in the post-partum period: clinical challenges, normal findings, and common imaging pitfalls

Complex physiological and biochemical changes occur in women during the post-partum period, many of which are incompletely understood. There are limited descriptions within the medical literature about expected imaging findings during this period and this review aims to illustrate 'normal' appearances following vaginal delivery and Cesarean section. We will also discuss some of the pertinent clinical challenges and imaging pitfalls encountered in assessing the post-partum female.

The postpartum ultrasound scan

Ultrasound assessment of the postpartum uterus has a significant role to play in the evaluation of a large proportion of symptomatic puerperal women. Often the imaging modality of choice for excluding retained placental tissue, correct application of postpartum ultrasound could enable more accurate identification of women requiring surgical intervention, with consequent reduction in patient morbidity and clinical workload. This article aims to review the current understanding and application of ultrasound in the puerperium and evaluate the current evidence investigating the physiological and pathological findings of the postpartum uterus and its contents.

Ten-Year Experience with the Conservative Management of Abnormally Invasive, Residual Trophoblastic Disease. A Retrospective Case Series

Conservative management of abnormally invasive, residual trophoblastic disease (AIRTD) is underreported. We aimed at critically reviewing our experience with such conservative management. We conducted a retrospective cohort study that included 24 women. The median completed week of gestation at delivery (20/24, 83.3%)/2nd trimester miscarriage (4/24, 16.7%) was 35 (range 17-41). Two women initially chose a surgical treatment (dilatation and curettage), but AIRTD remained sonographically visible afterward. Five patients developed a fever >38.0°C for ≥2 days (5/24, 20.8%). Due to heavy vaginal bleeding, 2 patients then underwent dilatation, diagnostic hysteroscopy, and curettage (2/24, 8.3%). One of these women also had to undergo hysterectomy (1/24, 4.2%). The 23 patients without hysterectomy underwent regular sonographic follow-up examinations. Regression of AIRTD was found after a median of 74 days (range 36-323). In conclusion, our data suggest that a conservative, observational treatment is feasible in AIRTD, with low rates of secondary surgical interventions. The long time intervals until regression require perseverance by these patients.

Multimodality imaging of the postpartum or posttermination uterus: evaluation using ultrasound, computed tomography, and magnetic resonance imaging

Postpartum and posttermination complications are common causes of morbidity and mortality in women of reproductive age. These complications can be broadly categorized into vascular, infectious, surgical, and neoplastic etiologies, or are due to ectopic implantation of placental or endometrial tissue. Causes of postpartum vascular complications include retained products of conception, arteriovenous malformation, and pseudoaneurysm. Infectious entities include endometritis, abscess, wound cellulitis, and pelvic septic thrombophlebitis. Postsurgical complications include uterine scar dehiscence, bladder flap hematoma, and subfascial hematoma. Neoplastic complications include the spectrum of gestational trophoblastic neoplasms. Ectopic tissue implantation complications include abnormal placentation and uterine scar endometriosis. Imaging is essential for diagnosis, and radiologists must be familiar with and aware of these entities so that accurate treatment and management can be obtained. In this review, we illustrate the imaging findings of common postpartum and posttermination complications on ultrasound, computed tomography, and magnetic resonance imaging.

Added value of 3-dimensional sonography for endometrial evaluation in early puerperium

OBJECTIVES

The purpose of this study was to examine the uterine cavity within 48 hours of delivery using 2- and 3-dimensional sonography after normal vaginal deliveries, instrumental deliveries, exploration of the uterine cavity, and cesarean deliveries.

METHODS

A prospective study was performed in puerperal women with normal clinical examination findings. Measurements of the uterine length and width were taken in the midsagittal and coronal planes. Midsagittal measurements of the endometrium using 2- and 3-dimensional sonography and virtual organ computer-aided analysis were performed. Comparisons were made between normal and surgical vaginal deliveries, cesarean deliveries, and after exploration of the uterine cavity.

RESULTS

A total of 123 patients were examined. Seventy-seven patients had normal vaginal deliveries; 21 had assisted vaginal deliveries; and 25 had cesarean deliveries. Thirteen underwent exploration of the uterine cavity. The uterine volume increased significantly as the birth weight increased and after cesarean delivery (P < .05). No correlation was found between the endometrial volume and parity, birth weight, and mode of delivery, including no correlation with exploration. Five cases of placental residua were found in asymptomatic women. All delivered vaginally. None underwent exploration of the uterus. All had irregular echogenic masses in the uterine cavity with positive color Doppler findings. The endometrial thickness and volume were significantly higher in these patients.

CONCLUSIONS

Sonography along with Doppler assessment has added value in the clinical evaluation of the puerperal women, being able to also show residua in asymptomatic women. Three-dimensional sonography did not show an advantage over 2-dimensional sonography in the estimation of the puerperal uterus or residua.

Ultrasound of the postpartum uterus

The ultrasound findings in the postpartum uterus will be described with a focus on differentiating normal from pathologic conditions. Imaging of the postpartum uterus will include a discussion of the normal postpartum uterus, postpartum hematomas, and retained products of conception. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients

OBJECTIVE

The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage.

STUDY DESIGN

One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding.

RESULTS

Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001).

CONCLUSION

A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.

Women and bleeding disorders

SUMMARY

While women are rarely affected by haemophilia, they are equally as likely as men to have other bleeding disorders. Menorrhagia, or heavy menstrual bleeding, is the most common symptom that they experience. Not only is menorrhagia more prevalent among women with bleeding disorders, but bleeding disorders are more prevalent among women with menorrhagia. Although menorrhagia is the most common reproductive tract manifestation of a bleeding disorder, it is not the only manifestation. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. Women suspected of having a bleeding disorder or being a carrier of haemophilia should be offered diagnostic testing before getting pregnant to allow for appropriate preconception counselling and pregnancy management. During pregnancy, women with bleeding disorders may be at an increased risk of bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. As women with bleeding disorders grow older, they may be more likely to manifest gynaecological conditions which present with bleeding. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, women with bleeding disorders are disproportionately affected by conditions that manifest with bleeding. Optimal management involves the combined expertise of haemostasis experts and obstetrician-gynaecologists.

Obstetric management of adolescents with bleeding disorders

Adolescents with bleeding disorders who become pregnant must contend with the dual challenges of their bleeding disorder and their pregnancy. Adolescents are more likely to terminate a pregnancy than adult women, and when they do carry a pregnancy, they are more likely to deliver prematurely. Otherwise, they are at risk for the same complications that adult women with bleeding disorders experience, particularly bleeding complications postpartum. Since one half to two thirds of adolescent pregnancies are unplanned, issues related to reproduction should be addressed during routine visits with the pediatrician, hematologist or gynecologist. Girls who are at risk of being carriers for hemophilia A and B, severe von Willebrand disease, and other severe bleeding disorders should have their bleeding disorder status determined before they become pregnant. During pregnancy, a plan should be established to ensure that both mother and fetus deliver safely. Young women at risk for severe bleeding or at risk of having a severely affected infant should be referred for prenatal care and delivery to a center where, in addition to specialists in high-risk obstetrics, there is a hemophilia treatment center or a hematologist with expertise in hemostasis. Prior to delivery or any invasive procedures, young women at risk for severe bleeding should receive prophylaxis. Since administration of desmopressin may result in hyponatremia, whenever available, virally inactivated or recombinant clotting factor concentrates should be used for replacement as opposed to fresh frozen plasma or cryoprecipitate.

Retained products of conception: spectrum of color Doppler findings

OBJECTIVE

The purpose of this study was to characterize color Doppler imaging features of retained products of conception (RPOC) with gray scale correlation.

METHODS

Clinically suspected cases of RPOC between January 2005 and February 2008 were reviewed. Patient data and relevant color Doppler and gray scale features were recorded.

RESULTS

A total of 269 patients referred for sonographic evaluation for RPOC were identified. Thirty-five patients had confirmed pathologic diagnoses, 28 of whom had RPOC. In those with RPOC, 5 (18%) were avascular (type 0); 6 (21%) had minimal vascularity (type 1); 12 (43%) had moderate vascularity (type 2); and 5 (18%) had marked vascularity (type 3). Peak systolic velocities ranged from 10 to 108 cm/s (average, 36.1 cm/s). Resistive indices in arterial waveforms ranged from 0.33 to 0.7 (average, 0.5). Five (45%) of the patients with type 0 vascularity had RPOC; 6 (86%) of those with type 1 had RPOC; and 17 (100%) of those with types 2 and 3 had RPOC. An echogenic mass had a moderate positive predictive value (80%) but low sensitivity (29%) for RPOC.

CONCLUSIONS

Color Doppler evaluation of the endometrium is helpful in determining the presence of RPOC. Endometrial vascularity is highly correlated with RPOC, whereas the lack of vascularity can be seen in both intrauterine clots and avascular RPOC.

Ultrasound examination of the postpartum uterus: what is normal?

OBJECTIVE

To establish normal ultrasonographic findings for the postpartum uterus after vaginal delivery, and to characterize associated bleeding patterns.

METHODS

Postpartum women were scanned by transabdominal ultrasound within 48 h after normal vaginal delivery. Uterine length, uterine width, endometrial stripe thickness and endometrial contents were evaluated by a single sonographer. Patients maintained a daily symptom diary for 6 weeks and were interviewed by telephone at 2 weeks. Statistical analysis was performed using chi2, Fisher's exact test, Student's t test and Pearson correlation.

RESULTS

Mean endometrial stripe thickness was 1.1 +/- 0.6 cm, mean uterine length was 16.1 +/- 1.7 cm and mean uterine width was 8.7 +/- 1.0 cm. Postpartum bleeding requiring more than four protective pads per day for > or =10 days was associated with a thicker endometrial stripe (1.5 +/- 0.7 cm vs. 0.9 +/- 0.4 cm, p = 0.006). However, no patients experienced postpartum bleeding complications requiring intervention. Of the 40 women evaluated, 16 had echogenic material in the uterine cavity (mean size 12.7 +/- 6.9 cm2). The presence of echogenic material was not associated with the amount or duration of bleeding.

CONCLUSIONS

Frequent postpartum ultrasonographic findings include a thickened endometrial stripe and echogenic material in the uterine cavity. The echogenic material commonly seen in the endometrial cavity of asymptomatic patients was not associated with the development of bleeding complications.

Abdominal and pelvic ultrasound findings within 24 hours following uneventful Cesarean section

OBJECTIVES

To describe prospectively the normal abdominal and pelvic ultrasound features within 24 h following uneventful Cesarean section.

METHODS

Transabdominal ultrasound examination was performed between 1 and 3 h, and again at 24 h, following lower-segment Cesarean section (LSCS). The myometrium, endometrium, and amount and distribution of free peritoneal fluid were studied in 30 women with singleton pregnancies who underwent LSCS delivery.

RESULTS

Examinations were performed easily in all cases except one who was morbidly obese (body mass index > 40 kg/m(2)). At 1-3 h after delivery, mean +/- SD endometrial thickness was 13 +/- 2 mm. Mean uterine length, from the fundus to the cervical external os, was 160 +/- 15 mm. Measurement of uterine length in the mid-sagittal plane of the pelvis was impossible in eight cases (27%) owing to pain. No abnormal intrauterine findings were observed. Mean uterine width was 110 +/- 10 mm. Mean distance between the sacral promontory and uterine fundus was 104 +/- 11 mm. Mean thicknesses of the anterior and posterior walls of the uterus were 40 +/- 5 mm and 39 +/- 7 mm, respectively. No fluid was seen in Morrison's or Douglas' pouches. There was a consistent and significant reduction between the measurements performed at 1-3 h and those at 24 h after LSCS, except for the distance between the fundus and external os.

CONCLUSIONS

Ultrasound examination is feasible after Cesarean section. Images are obtained easily, even when scanning through the scar. In normal pregnancies, there is no fluid in the abdomen or pelvis. These results could help clinicians in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability following LSCS.

Occurrence and outcome of residual trophoblastic tissue: a prospective study

OBJECTIVE

The purpose of this study was to evaluate the occurrence of residual trophoblastic tissue after miscarriage or delivery, to assess the diagnostic value of sonography with color Doppler examination in the detection of retained tissue, and to define in what cases expectant management may be an option.

METHODS

We conducted a prospective observational study using sonography with color Doppler imaging in consecutive patients at routine follow-up after miscarriage or delivery. Expectant management was proposed in all patients with suspected retained tissue providing they were hemodynamically stable and in the absence of signs of infection. In case of surgical removal of retained tissue, the histologic examination was compared with the sonographic findings.

RESULTS

In total, 1070 patients were assessed. In 67 patients (6.3%), sonographic and color Doppler examination showed retained tissue, and in 41 (61%) of them, curettage was performed. In all but 1 case, retained tissue was confirmed on histologic examination. Cases of retained tissue were more often seen after first-trimester (17%) or second trimester (40%) miscarriage, in the presence of abnormal uterine bleeding (57%), and with areas of enhanced myometrial vascularity (77.3%).

CONCLUSIONS

Sonography with color Doppler examination is clinically useful to confirm or exclude residual trophoblastic tissue.

Routine postpartum ultrasonography in the prediction of puerperal uterine complications

OBJECTIVES

To determine whether there is a relationship between the findings of routine postpartum ultrasonographic scanning and puerperal uterine complications such as heavy delayed postpartum hemorrhage, retained products of conception, and need for uterine curettage; and to estimate the value of both routine ultrasonographic scanning and clinical data in the prediction of these complications.

METHODS

In this cohort study 265 women were examined ultrasonographically on postpartum Days 1, 14, 42 following uncomplicated vaginal or cesarean deliveries. They were divided into a low-risk (n=149) and a high-risk (n=116) group according to predefined risk factors for puerperal uterine complications. The ultrasonographic findings were dichotomized into no masses (endometrial strip, endometrial fluid, or hyperechoic foci) or a definite intrauterine echogenic/heterogeneous mass (IUM, >15 mm in diameter).

RESULTS

The presence of risk factor(s) was significantly associated with uterine subinvolution, IUM, heavy delayed postpartum hemorrhage (PPH), and a need for uterine curettage. Multivariable logistic regression analysis for the risk factor(s) that can predict the occurrence of heavy delayed PPH showed that the presence of an IUM was the most predictive variable. The presence of an IUM and heavy delayed PPH predicted uterine curettage in 61.3% and 37.5% of patients, respectively.

CONCLUSION

Routine uterine scanning on Day 1 and Day 14 postpartum is an easy, inexpensive, valuable method that can be offered to women at high risk for delayed PPH due to subinvolution or the presence of an IUM. Accordingly, it may be predicted which women will benefit from uterine curettage in up to two-thirds of cases.

Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue

OBJECTIVES

To describe sonographic findings associated with retained placental tissue in patients with secondary postpartum hemorrhage, and to compare these findings with those of women with a normal puerperium.

METHODS

This was a prospective observational study of 79 women with secondary postpartum hemorrhage. Ultrasound examinations were performed on the day the patients presented with clinical symptoms and were scheduled for postpartum days 1, 3, 7, 14, 28 and 56, continuing until uterine surgical evacuation was performed or until the bleeding stopped. The maximum anteroposterior (AP) diameters of the uterus and uterine cavity were measured and morphological findings in the cavity were recorded. The findings were compared with previously published results from a normal population.

RESULTS

The patients were divided into two groups. Group 1 (n = 18) underwent surgery and Group 2 (n = 61) was treated conservatively. Sonography revealed an echogenic mass in the uterine cavity in 17 patients from Group 1, and in 14 of these patients histology confirmed placental tissue. The AP diameter of the uterine cavity was above the 90(th) percentile in all but two of the 18 Group 1 patients. In 18 patients from Group 2 the cavity was empty and in 43 a mixed-echo pattern was found. The uterine cavity was wider compared with the controls, but the values largely overlapped.

CONCLUSION

This report supports the opinion that the sonographic finding of an echogenic mass in the uterine cavity in women with secondary postpartum hemorrhage is associated with retained placental tissue.

Ultrasound of the post-partum uterus

AIMS

To assess the appearance of the post-partum uterus on transabdominal ultrasound, and to correlate these findings with maternal morbidity.

METHODS

In a prospective observational study, 94 women were seen within 24 h of their delivery and assessed by transabdominal ultrasound. Volumetric data were calculated from measurements of intrauterine echogenic areas. All women were contacted for a telephone interview 1-4 months following their delivery to assess whether they had experienced morbidity associated with their delivery such as post-partum haemorrhage, pyrexia, prolonged hospital stay, follow-up investigations or surgical intervention.

RESULTS

Two areas of echogenic material were identified in the upper and lower segment of the post-partum uterus. These were assessed independently for dimensions and volumes. The upper segment area had an average thickness of 13.8 mm and an average volume of 35.6 cm(3) The lower segment/cervical area held considerably more material with an average volume of 54.8 cm(3). The mean duration of post-partum bleeding was 4.2 weeks. None of the recruited women required a blood transfusion. The average hospital stay was 4 days. Twenty-two (23%) of the participants experienced a febrile illness following delivery, and 19 (20%) were commenced on antibiotics. None of these parameters of post-partum morbidity were associated with the ultrasound findings.

CONCLUSIONS

In this study ultrasound evaluation in the immediate post-partum period revealed unexpectedly large volumes of echogenic material in the uterine cavity. However, such volumes of echogenic material were not associated with postnatal morbidity, and can probably be accepted as normal.

Von Willebrand Disease

Von Willebrand disease (VWD), the most common inherited bleeding disorder, results from a deficiency of von Willebrand factor (VWF), a protein required for the normal adhesion of platelets to the site of injured endothelium and for preservation of factor VIII in the circulation. The prevalence of VWD has been reported to be as high as 1.3%. Among women with VWD, menorrhagia is the most common symptom, affecting 32% to 100%. Treatments that have been reported to control menorrhagia in these women include combined oral contraceptives, 1-deamino-8-D-arginine vasopressin (DDAVP), tranexamic acid, and the levonorgestrel-releasing intrauterine system. With the exception of nonsteroidal antiinflammatory drugs, any treatments effective in the treatment of menorrhagia, including hysterectomy, may be suitable. Besides menorrhagia, women with VWD appear to be at an increased risk of developing hemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions that present with bleeding such as fibroids, endometrial hyperplasia, and polyps. During pregnancy, they may be at greater risk of miscarriage and bleeding complications, particularly delayed or secondary postpartum hemorrhage. Vaginal or vulvar hematomas, extremely rare in women without bleeding disorders, are not uncommon. Although women with VWD are at risk for the same obstetric and gynecologic problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that Von Willebrand Disease (VWD) is a common inherited disease, especially in women with menorrhagia; state that prophylaxis therapies against bleeding in pregnant and nonpregnant women are available; and explain that, despite prophylaxis, miscarriage and bleeding complications can still occur.

More than menorrhagia: a review of the obstetric and gynaecological manifestations of bleeding disorders

In women, menorrhagia may be the most common manifestation of a bleeding disorder, but it is not the only reproductive tract abnormality that women with bleeding disorders experience. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions, which present with bleeding such as fibroids, endometrial hyperplasia and polyps. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. Vaginal or vulvar haematomas, extremely rare in women without bleeding disorders, are not uncommon. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding.

The sonographic and color Doppler features of retained products of conception

OBJECTIVE

The purpose of this study was to identify the sonographic features of retained products of conception (RPOCs).

METHODS

Cases of clinically suspected RPOCs referred for pelvic sonography between September 1994 and July 2001 were identified. Patient age, indication, gestational age at delivery, and days postpartum were recorded and sonographic findings were reviewed. Outcomes were determined from medical records and pathology reports.

RESULTS

One hundred sixty-three cases were identified. Indications for pelvic sonography included vaginal bleeding in 82 (50%), pelvic pain in 77 (47%), and fever in 55 (34%). Gestational age at delivery ranged from 14 to 43 weeks (mean, 37 weeks), and the sonographic examination was performed from 0 to 95 days postpartum (mean, 21 days). Thirty-six patients underwent surgical intervention, and 28 of these had RPOCs. The remaining 127 patients were followed clinically. An endometrial mass was the most sensitive (79%) and specific (89%) sonographic feature for RPOCs. The isolated finding of either complex fluid in the endometrial canal or a thick endometrium measuring greater than 10 mm had low sensitivity, specificity, and negative and positive predictive values. None of the patients with RPOCs had normal sonographic findings. The absence of an endometrial mass or complex fluid and an endometrial thickness of less than 10 mm were considered normal findings. Color Doppler flow was detected in the endometrium somewhat more often when RPOCs were present than in the absence of RPOCs (75% versus 40%).

CONCLUSIONS

An endometrial mass is the most sensitive finding for RPOCs. If no mass or endometrial fluid is seen and the endometrial thickness is less than 10 mm, RPOCs are extremely unlikely. The absence of blood flow does not exclude the diagnosis of RPOCs.

Prospective evaluation of blood flow in the myometrium and uterine arteries in the puerperium

OBJECTIVE

Heavy bleeding in the late postpartum has, in some cases, been attributed to subinvolution of the placental bed and enhanced myometrial vascularity (EMV) as seen on color Doppler imaging. The aim of this study was to investigate the incidence and spontaneous evolution of areas of enhanced vascularization over the whole thickness of the myometrium in asymptomatic women after uncomplicated term pregnancy.

METHODS

This was a prospective descriptive study involving 93 consecutive women who were examined on day 3 (mean 2.6 +/- 1.5) and at 6 weeks (mean 6.5 +/- 1.3) after delivery following an uncomplicated term pregnancy. EMV was defined as the presence of marked flow over the full thickness of the myometrium reaching the uterine cavity. Doppler flow examination within the area of EMV and of both uterine arteries was performed.

RESULTS

The mean patient age was 29.1 years and average parity was 1.7. The mean gestational age at delivery was 39.1 weeks. Areas of EMV were visualized in 50.5% of patients on day 3 vs. 3.9% at 6 weeks. None of the patients required therapy for bleeding problems. The mean pulsatility index and peak systolic velocity in the area of EMV on day 3 were 0.45 +/- 0.30 and 0.37 +/- 0.20 m/s, respectively. A consistent increase in vascular resistance and decrease in blood flow velocity was observed in both uterine arteries between day 3 and week 6.

CONCLUSIONS

Most areas of EMV reflect intermediate stages in the involution of the placental bed and do not cause abnormal postpartum bleeding. EVM is common in the puerperium, disappears spontaneously in the vast majority of cases, and does not warrant treatment if asymptomatic. Further research is needed to predict the rare cases in which subinvolution of the placental bed leads to heavy bleeding in the late postpartum.

Color Doppler and gray-scale ultrasound evaluation of the postpartum uterus

OBJECTIVES

To evaluate the color Doppler and gray-scale sonographic appearance of the uterus after pregnancy, with special attention to the occurrence of areas of enhanced vascularity and placental remnants.

PATIENTS AND METHODS

Cross-sectional observational study involving 385 consecutive women presenting at their first visit after pregnancy. The uterus was evaluated using ultrasound with color Doppler. In the presence of placental remnants, blood was sampled for measurement of beta human chorionic gonadotropin (beta hCG), hemoglobin (Hb) and infectious parameters. If indicated, a dilatation and curettage was performed.

RESULTS

In 8.3% of women, areas of enhanced vascularity were detected with color Doppler examination. Most cases (68.9%) were focal areas of one or more vessels. In 2.6% of patients abnormal vascularity extended over a large area of the whole myometrium. In 6.75% of cases, placental remnants were detected. In 46% of these, blood sampling revealed beta hCG levels below 30 mIU/mL; serological infection parameters and Hb concentration were within the normal range.

CONCLUSIONS

Areas of enhanced vascularity of the uterus, ranging from a focal vascular pedicle to a larger area of the myometrium, are relatively common after pregnancy. They are predominantly seen in the presence of placental remnants, in the early postpartum period and after instrumental or manual delivery of the placenta. There are no clear risk factors for retained placental tissue, besides the history of blood transfusion in the early postpartum, and perhaps multigravidity. Serology is of little help in the diagnosis of retained gestational products. The knowledge of the ultrasound and color Doppler features of the uterus after pregnancy may prove of practical value for the management of abnormal uterine bleeding in the postpartum period.