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

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.

Ultrasonographic examination of postpartum uterine involution in sows

Physiological uterine involution during the puerperium period is essential for sow reproductive health. Uterine involution in sows has mainly been described using macroscopic and histological examination after slaughter. The aim of this study, therefore, was to describe the continuous regression of uterine diameter from day 2-14 after parturition and on the day before weaning using ultrasonography in sows housed in a free farrowing system and in farrowing crates. Diameter of three uterine cross-sections was measured at 24 -hs intervals in 46 sows housed in a free farrowing system in Switzerland and 49 sows housed in farrowing crates in Germany. Overall, there was continuous regression of uterine diameter during the lactation period in both groups. Median diameter of the uterus decreased from 32.4 mm (min: 18.6 mm, max: 52.3 mm) on day 2-9.0 mm (min: 7.6 mm, max: 12.7 mm) on the day before weaning (on average 30 days p.p.) in sows housed in free farrowing systems. Median diameter of the uterus of sows in farrowing crates decreased from 38.5 mm on day 2 (min: 21.6 mm, max: 56.3 mm) to 10.1 mm (min: 8.8 mm, max: 13.6 mm) the day before weaning (on average 29 days p.p.). Interestingly, parity, obstetrical intervention and administration of oxytocin was not associated with the decrease of uterine diameter during the study period. In summary, the ultrasonic examination is a suitable method to evaluate diameter of the uterus during the puerperium period in sows and to describe uterine involution in vivo.

Evaluating the Endometrial Hyperechoic Zone in Early Postpartum Women May Be Deceptive When Utilizing Transcutaneous Sonography

The objective of this study was to investigate the concordance of measurements for early postpartum endometrial thickness between magnetic resonance imaging (MRI) and transcutaneous diagnostic medical sonography (DMS) as well as its implications. The measurements of early postpartum endometrial thickness were reviewed across 51 postpartum women who underwent MRI and transcutaneous DMS. Additionally, 30 women with a normal menstrual cycle formed a control group, and their data were compared. The results indicated that the endometrial thickness at early postpartum was 4.63 ± 0.62 mm on MRI and 8.18 ± 4.70 mm on DMS, with a comparative significant difference ( P < .001). The endometrial thickness of the control group was 10.02 ± 1.71 mm on MRI and 10.17 ± 1.81 mm on DMS with no comparative significant difference ( P = .124). This cohort study questions whether the hyperechoic zone in the early postpartum uterine cavity represents the actual endometrial thickness. Care should be taken by sonographers in labeling the hyperechoic zone in the early postpartum stage as endometrium.

[Ultrasound appearance of the area of uterine closure in asymptomatic patients at 48 hours of uneventful cesarean section]

OBJECTIVE

It seeks to assess the appearance of the hysterorrhaphy area and seeks hematoma in asymptomatic patients at 48hours of their cesarean.

METHOD

It is common to see, ultrasound or CT scan, collection of images next to the hysterorrhaphy area in symptomatic patients after cesarean. Their interpretation remains difficult which led us to propose a prospective study looking for an evocative image collection or hematoma in asymptomatic patients at 48hours of their cesarean. It was directed suprapubic and transvaginal pelvic ultrasound with study area hysterorrhaphy and inter-uterine bladder space.

RESULTS

The suprapubic ultrasound examination was performed in 31 asymptomatic patients after collecting their written consent. Twenty-eight patients also received an endovaginal examination. The studied area was easily identified by visualizing the path of hysterotomy and hyperechoic aspect of the hysterorrhaphy. In 28 cases there were no abnormal image in front of the hysterorrhaphy area. In 3 cases, an evocative image of a haematic collection was displayed and measured a maximum of only 49mm long axis with a weak Doppler signal. The exam was very well tolerated by patients, especially by transvaginal route. Also the duration of ultrasound never exceeded 58seconds and remained fastest vaginally.

CONCLUSION

This preliminary work to a prospective double cohort (symptomatic patients and asymptomatic patients) has clarified the technique to use and focus in the search for a collection next to the hysterorrhaphy area. Ultrasound examination postoperatively, especially vaginally, is very fast, well tolerated with satisfactory image quality. Finally in this cohort of asymptomatic patients, it was very unusual for a collection, confirming the credit to be given to this type of image in case of symptoms after cesarean.