What is Subinvolution?

It is a condition where the uterus is delayed to return to its pre-pregnant state after childbirth
during the postpartum period of 6-8 weeks. The normal involution of the uterus begins during the
3rd stage of labor, accelerates after the expulsion of the placenta and continues over the next 6-8
weeks for the organ to prepare for the next pregnancy. The uterus may be larger or softer than
expected for a postpartum date.

Predisposing Factors Aggravating Factors

Overdistended Uterus Retained Product of Conception

Grand Multipara Endometritis
Uterine Fibroid of Myometrium
Retroversion of Uterus

1. Predisposing Factor:

1.1. Overdistended Uterus

Overdistended uterus happens when the uterus involving its muscle cells reaches its peak
of stretch. The myometrial muscle cells were extended to the point of the difficulty to return
back to its non-stretched state. This might happen to patients with polyhydramnios and fetuses
that are large for gestational age. Due to the stretch caused by delivery an influx of sodium is
released acting on the calcium and causes continuous contraction therefore increasing the tension
in the myometrial cell. Sodium influx sends a message within the muscle fibers to trigger the
release of stored calcium ions. The calcium ions then initiate the smooth muscle contractions by
binding to calmodulin and activating the enzyme myosin light chain kinase. Myosin is a motor
protein best known for aiding muscle contraction. The continuous contraction may be compared
as prolonged labor which is a risk factor for uterine atony. After prolonged contraction the
myometrium has lost its tonicity causing the delay in involution of the uterus.

1.2. Grand Multipara

Grandmultiparity can sometimes be a factor in overdistension of the uterus.

Grandmultipara deals with parity of more than five. This situation causes the uterine lining to be
thin due to the hormone estrogen after each delivery. Estrogen is the main factor which causes
the thickening of the uterine wall and promotes vascularization during pregnancy. After delivery
the estrogen level decreases rapidly causing the thinning of uterine lining. Due to grand
multiparity the thickening and thinning out of the uterine lining is repetitively occuring. The
number of parity causes the repetitive mechanical stretch of the uterus or hypertrophy. The
uterine stretch causes the synthesis of a specific kind of prostaglandin also called prostacyclin
(generated by endothelial cells has something to do with inflammation due to vasodilation).
This kind of prostaglandin plays a major role in the vasodilation of the uterine wall and is a
potent endogenous inhibitor of platelet aggregation. Prostacyclin inhibits platelet aggregation
by increasing cyclic AMP levels. Increased cAMP in smooth muscles causes relaxation. cAMP
normally inhibits myosin light chain kinase. The thinning of the uterine wall with the relaxation
due to mechanical stretch sums up to cause weakened muscle cells. Therefore leads to the high
tendency of the uterus to lose its contractility and tonicity. These processes can cause the
subinvolution of the uterus.

1.3. Uterine Fibroid

Uterine fibroids are noncancerous growths of the uterus that often appear in the
chilbearing years. They are usually round and are composed of the same smooth muscle fibers as
the uterine wall (myometrium) but are denser than the normal myometrium. Fibroids respond to
the hormone estrogen and tend to enlarge during the reproductive years causing the distortion of
the uterine architecture. Due to the enlargement of the fibroids during pregnancy they may
outgrow their blood supply and degenerate. Patients with very large fibroids may experience
necrosis of the fibroids, which causes inflammation and swelling of the uterus after pregnancy.
With the inflammation present at the involution process an interference in myometrial
contractions may occur due to weakened function of the myometrium to contract. It can be
classified as uterine atony and leads to subinvolution.

1.4. Retroversion of the Uterus

A retroverted uterus is a uterus that curves in a backwards position at the cervix instead
of a forward position. After delivery a malposition of the uterus may occur with factors including
how the ligaments have stretched during pregnancy or how much you gained weight ( added
weight puts pressure on your uterus and can affect its postpartum position). Due to retroverted
uterus a problem may occur such as the weakening of the pelvic ligaments after childbirth
causing the decreased function of the uterus to contract. The stretched ligaments may also cause
the retroversion to stay in its tipped backward position causing the grown and stretched uterus to
be snagged on the pelvic bone (the sacrum area) called the incarcerated uterus. As it is trapped
on the sacrum area the uterus may experience the decreased function or atony and may cause
delayed involution.

2. Aggravating Factors:

2.1. Retained Product of Conception

The term Retained Product of Conception refers to intrauterine tissue that develops after
the conception and persists after delivery or termination of pregnancy. The placenta usually
constitutes the RPOC. RPOC is somehow involved with dystocia or abnormal labor due to the
failure of the retroplacental myometrium (region behind the placenta) to contract. Abnormal
labor is classified as slow and not progressing contraction of the uterus during delivery. Dystocia
has insufficient contraction for placental detachment which leads to incomplete expulsion of all
the products of conception. The RPOC then causes continued contraction to be expelled and
usually is associated with Postpartum Hemorrhage. Failure of the retroplacental myometrium
and dystocia which lead to PPH can now be classified as uterine atony. And later leads to
subinvolution.
2.2. Endometritis

Endometritis is the inflammation of the inner lining of the uterus (endometrium). It is

classified with an ascending infection from the lower part of the genital to the upper part of the
uterus. The inflammation causes the increased blood flow due to vasodilation. In the normal
involution, there is a blood clotting which prevents the bleeding and to occlude the spiral
arteries. In Endometritis the inflammation associated with vasodilation causes the fundal area
to be tender which promotes blood flow. The spiral arteries are unable to occlude causing
continued blood flow. The inflammation causes the uterine atony. This particular situation then
tends to make the uterus in prolonged enlargement causing slow involution.

Signs:

Signs include:

Uterine height is greater than normal for the particular day of puerperium

Uterus may feel boggy and softer upon palpation

Symptoms:

Symptoms include:

Abnormal lochial discharge (excessive or prolonged)

Irregular or at times excessive bleeding

Irregular cramp like pain

Management:

Medicine or uterine massage to stimulate uterine contraction.

Uterine and pelvic examination to determine which part needs repair

Decreasing of estrogen release for patients with uterine fibroids.

Hormonal therapy ( usually with patients with U.F)

Surgical intervention with some patients with RPOC

Management of iron deficiency due to bleeding.

Suggested sleeping of the mother to her stomach for days to tipped the retroverted uterus
forward.

Pessary or surgery for a retroverted uterus.

Administration of methylergonovine,0.2 mg 4x a day to improve uterine tone

Oral Antibiotic for infection such as endometritis

Physician may prescribe iron supplements to aid in the blood loss of the client with
postpartum hemorrhage