Ultrasound of the postpartum uterus

The role of ultrasound in the diagnosis and management of postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of death or severe morbidity for the mother after delivery. As a consequence healthcare staff working in the delivery room should be trained to perform a prompt diagnosis and adequate management of PPH. Uneventful outcome is induced correct identification of the underlying cause of hemorrhage. Ultrasound is a promising technique for the prompt diagnosis of PPH etiology. Indeed, it is easily available, with relatively low cost, not using ionizing radiation, and can be used in different settings including the labor room, the operating theater and at the bedside of an affected women. In order to be effective Obstetricians should have an adequate knowledge of postpartum ultrasonography. In this article, we will review the sonographic findings occurring in PPH, in the differential diagnosis of the underlying cause of hemorrhage, that include retained placenta, morbidly adherent placenta, rupture of the uterus uterine, vascular anomalies of the uterine arteries and uterine inversion. We will also provide an algorithm to manage PPH according to the ultrasonographic findings.

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.

Early Prediction of Blood Loss and Postpartum Hemorrhage after Vaginal Delivery by Ultrasound Measurement of Intrauterine Content

The ability of ultrasound to predict postpartum hemorrhage remains poorly described. The aim of this study was to evaluate whether ultrasound measurement of intrauterine content can predict blood loss and postpartum hemorrhage after vaginal delivery. We used a preliminary prospective monocentric study of 201 women who delivered vaginally after 34 wk of gestation. Measurements were performed 30-45 min after normal vaginal delivery according to strict ultrasonographic criteria. Analysis of the relationship between ultrasound measurements and hemoglobin loss showed a strong linear correlation (R² = 0.59 and R² = 0.4 for isthmic and fundal measurements). The maximal value between the fundal and isthmic measurements seems to provide the best accuracy to predict loss of hemoglobin higher than 3 g/dL (area under the curve [AUC] of the receiver operating characteristic curve, 0.9; 95% confidence interval [CI], [0.76-0.97]) and post-partum hemorrhage (AUC, 0.99; 95%CI, [0.984-0.99]). In case of intrauterine content >2 cm (135/201), the risks of loss of hemoglobin higher than 3 g/dL (5/135 vs. 0/66) and post-partum hemorrhage (11/135 vs. 0/66) were increased, all the more if the intrauterine content was >4 cm (4/16 and 11/16, respectively). Considering the maximal measurement, the most optimal cut-off value for clinical practice could be 2.4 cm (sensibility 100%, specificity 57%) and 4.1 cm (sensibility 100%, specificity 97%) for loss of hemoglobin higher than 3 g/dL and post-partum hemorrhage, respectively.

The value of postpartum ultrasound for the diagnosis of retained products of conception: A systematic review

BACKGROUND

The goal of this review is to evaluate the value of ultrasound for detection of retained products of conception (RCOP) after delivery.

METHODS

A systematic search was performed using 'postpartum', 'retained placenta', 'retained products' and 'ultrasound' resulting 82 publications, after screening titles and abstracts, 30 remained.

RESULTS

On gray scale ultrasound, one must be focus on a thickened endometrial echo complex (EEC) with a cut off value of 10 mm and on an intracavitary mass. If these features are not visible, RPOC is rare. However, these findings are neither specific nor conclusive for RPOC and can even be seen in a normal postpartum uterus. Detection of hypervascularity in a thickened EEC or intracavitary mass with color Doppler ultrasound is very sensitive for RPOC but still not specific nor can it exclude RPOC. MRI seems best in differentiating RPOC, arteriovenous malformations and gestational trophoblastic disease.

CONCLUSION

There is no consensus on a standardised method for postpartum ultrasound. More research and standardization are necessary to differentiate of normal and pathological findings in the postpartum uterus.