الرسالة كاملة

Zagazig University
Faculty Of Medicine
Obstetrics and Gynecology
Department
COMPARISON BETWEEN NORMAL LABOR AND CESAREAN

SECTION BY THE UTERINE ULTRASOUND PICTURE AT 7TH AND
40TH DAY POST-PARTUM
Thesis
Submitted For Partial Fulfillment of Master Degree
In Obstetrics and Gynecology
By
ALAA MOHAMED NAGEEB KAPIL
M.B.B.Ch – Zagazig University
Resident of Obstetrics and Gynecology
Supervisors
Prof. Dr. Prof. Dr.
MOHAMED NAGEEB AZAM AMAL MOHAMED AL ANWAR
Professor Obstetrics and Gynecology Department Professor of Obstetrics and Gynecology
Faculty of Medicine – Zagazig University Faculty of Medicine – Zagazig University
Dr.
WAEL SABRY NOSSAIR
Professor of Obstetrics and Gynecology
Faculty of Medicine – Zagazig University
Faculty of Medicine
Zagazig University
2020
‫جامعة الزقازيق‬
‫كلية الطب البشري‬
‫قسم التوليد وأمراض النساء‬
‫رسالة‬
‫توطئة للحصول على درجة الماجستير فى التوليد و أمراض النساء‬
‫مقدمة من‬
‫طبيب‪ /‬آالء محمد نجيب قابيل‬
‫بكالوريوس الطب والجراحة ‪ -‬جامعة الزقازيق‬
‫طبيب مقيم التوليد و أمراض النساء‬
‫المشرفون‬
‫االستاذ الدكتور‬ ‫االستاذ الدكتور‬
‫أمل محمد األنور‬ ‫محمد نجيب عزام‬

‫استاذ التوليد و أمراض النساء‬ ‫استاذ التوليد و أمراض النساء‬
‫كلية الطب البشري – جامعة الزقازيق‬ ‫كلية الطب البشري – جامعة الزقازيق‬
‫الدكتور‬
‫وائل صبري نصير‬

‫مدرس التوليد و أمراض النساء‬
‫كلية الطب البشري – جامعة الزقازيق‬
‫كلية الطب البشري‬

‫جامعة الزقازيق‬
‫‪0202‬‬
CONTENTS
LIST OF CONTENTS
- List of Abbreviations II
- List of Tables IV
- List of Figures VI
- Introduction 1
- Aim of the work 3
- Review of Literature 4
Chapter (I): Physiological And Anatomical Changes

4
In The Uterus During Pregnancy
Chapter (II): Uterine Evaluation During Normal And

25
Abnormal Puerperium
Chapter (III): Normal Postpartum Findings On

29
Ultrasound
Chapter (IV): Ultrasound Finding In Abnormal
40
Puerperium
- Patients and methods 48
- Results 53
- Discussion 69
- Summary 76
- Conclusion and Recommendation 80
- References 82
- ‫الملخص العربي‬ ١
I
CONTENTS
II
ABBEREVIATIONS
ABBEREVIATIONS
2D two-dimensional
3D three-dimensional
ALT
AP Anteroposterior
AST
AV Arteriovenous
AVMs Arteriovenous Malformations
CBC Complete Blood Count
CS Caesarean section
Hz Hertz
IUM Intrauterine mass
MHz megahertz
NVD Normal vaginal delivery
PPH Primary postpartum hemorrhage
PSV Peak systolic velocity
RPOC
RPT Retained Placental Tissue
SPH Secondary postpartum hemorrhage
TV Transvaginal
US Ultrasound
II
TABLES
LIST OF TABLES
No Title Page
Table (1) Socio-demographic data of the two studied groups 53
Table (2) Gestational age at delivery among the two studied groups 55
Table (3) Breast feeding and day among the two studied groups 56
Width at 7th day and 40th day among the two studied
Table (4) 58
groups
Length at 7th day and 40th day among the two studied
Table (5) 59
groups
AP diameter at 7th day and 40th day among the two
Table (6) 60
studied groups
Cavity at 7th day and 40th day among the two studied
Table (7) 61
groups
Relation between breast feeding and different
Table (8) 63
measurement among NVD group
Relation between breast feeding and different
Table (9) 66
measurement among CS group
IV
FIGURES
LIST OF FIGURES
No Title Page
Schematic presentation of the longitudinal, oblique and
Figure (1) 5
circular muscle fibers of the pregnant uterus
A and B: (A) Marked elongation of The muscle fibers
Figure (2) during pregnancy, (B) Blood Vessels in between 6
interlacing muscle fibers.
The level of fundus uteri at different Weeks; Note the
Figure (3) 6
change of uterine shape
Figure (4) Parous and nonparous cervix. 14
chogenic mass within the endometrial cavity seen in the
Figure (5) sagittal plane on transvaginal scan 6 weeks post vaginal 34
delivery
Application of colour Doppler demonstrates trophoblastic
Figure (6) blood flow to the region of the echogenic mass, aiding 34
diagnosis of retained products of conception
Echogenic mass seen within the lower uterine segment in
Figure (7) the sagittal plane on transvaginal scan performed in a 35
symptomatic patient 8 weeks post vaginal delivery
Echogenic mass within the lower uterine segment in the
Figure (8) same patient as seen in the transverse plane on 35
transvaginal scan
Application of colour Doppler demonstrates trophoblastic
blood flow to the region of the echogenic mass in the
Figure (9) 36
transverse plane on transvaginal scan aiding diagnosis of
retained products of conception
(A) Transabdominal sagittal greyscale image and (B)
Figure (10) transvaginal color Doppler image from a 35-year-old 37
woman two weeks postpartum with vaginal bleeding.
The normal rotation process of the uterus during the
Figure (11) 39
puerperium
Figure (12) Age distribution of the two studied groups 53
Figure (13) Parity distribution of the two studied groups 54
Figure (14) Gestational age at delivery among the two studied groups 55
VI
FIGURES
Figure (15) Frequency of breast feeding among the two studied groups 56
Figure (16) Day among the two studied groups 57
Figure (17) Width among the two studied groups at 7th and 40th day 58
Figure (18) Length among the two studied groups at 7th and 40th day 59
AP diameter among the two studied groups at 7th and 40th
Figure (19) 60
day
Figure (20) Cavity among the two studied groups at 7th and 40th day 62
Different measurement among the NVD group according
Figure (21) 65
to breast feeding at 7th and 40th day
Different measurement among the CS group according to
Figure (22) 68
breast feeding at 7th and 40th day
VII
INTRODUCTION
INTRODUCTION
Puerperium is the time of adjustment after pregnancy and labor in
which charges of pregnancy are reversed and the body returns to the normal
pre-pregnant state. The principal change in pelvic organs during the
puerperium is uterine involution (Pessel and Tsai, 2013)
The uterus after birth undergoes several changes in size, shape,

position and contents
Primary and secondary post-partum hemorrhage and post-partum

septic endometritis are among the major causes of maternal mortality and
morbidity (Drife, 2005).
Placental tissue remaining inside the uterus after labor is associated

with a high risk of bleeding (Dewhurst, 1966).
It would be important to know the normal US shape of the uterus

at the 7h and 40 day after birth and compare between normal delivery and
CS images in order to increase our ability to distinguish puerperal
pathology form normal state and thus avoid unnecessary invasive
procedures. Moreover, the knowledge we gain through US examinations
can help us to understand physiology of the puerperium (Alexander et al.,
2002)
Our knowledge about postpartum changes in the uterus has mainly

been based on clinical examinations as well as on histological studies from
the end of the 19"century and the early part of the 20thcentury when
maternal death after labor was commonplace (Mulic-Lutvica, 2007).
1
INTRODUCTION
The involution of the uterus which is a main feature of the

puerperium was formerly assessed by palpation, which can he imprecise in
in woman with myoma of uterus (Paliulyte et al., 2017)
Since the introduction of US in clinical work by Ian Donald et al.

in 1958, the uterus became one of the first organs to be examined.
However, few studies have focused on US investigations during the
puerperium and results of published studies are not unambiguous (Mulic-
Lutvica, 2007).
Doppler ultrasound was used to measure flow resistance indices of

the uterine arteries during the menstrual cycle, daring both normal and
abnormal pregnancies and during labor. A small number of Doppler US
studies has been published regarding the hemodynamic events which occur
during the puerperium (Mulic-Lutvica, 2007).
During the last ten years the caesarean section rate has been steadily
rising and we can expect increasing placental complications in forthcoming
years (Zelop and Heffner, 2004). Caesarean section (CS) is one of the
leading predisposing factors for puerperal endometritis. The involution of
the uterus after CS has been studied but results are inconclusive. The
majority of published studies were related to postoperative complications.
The US appearance of the uterine wound after CS has been sparsely studied
(Mulic-Lutvica, 2007).
2
AIM OF THE WORK
AIM OF THE WORK

The aim of this study was to compare between normal labor and
caesarian section by the uterine ultrasound picture at 7 th and 40th day
postpartum.
3
REVIEW OF LITERATURE
PHYSIOLOGICAL AND ANATOMICAL

CHANGES IN THE UTERUS DURING
PREGNANCY
Throughout pregnancy there is a progressive anatomical,
physiological and biochemical change not only confined to the genital
organs but also to all systems of the body. This is principally a phenomenon
of maternal adaptation to the increasing demands of the growing fetus
(Konar, 2015).
As regard to the uterus; there is enormous growth of the uterus

during pregnancy as the uterus which in non-pregnant state weighs about
60 gm, with a cavity of 5-10 mL and measures about 7.5 cm in length, at
term, weighs 900-1000 g and measures 35 cm in length. The capacity is
increased by 500-1000 times. Changes occur in all the parts of the uterus;
body, isthmus and cervix (Konar, 2015).
This increase in growth and enlargement of the body of the uterus

occurs mainly by hypertrophy and hyperplasia in the muscles, not only the
individual muscle fiber increases in length and breadth but there is limited
addition of new muscle fibers, this occurs under the influence of the
hormones estrogen and progesterone limited to the first half of pregnancy
but pronounced up to 12 weeks (Konar, 2015). Beyond 20 weeks; the
muscle fibers further elongate due to distension by the growing fetus. The
wall becomes thinner measures about 1.5 cm or less at term. There is
simultaneous increase in number and size of the supporting fibrous and
elastic tissues (Fukuda et al., 2016).
4
The uterus feels soft and elastic in contrast to firm feel of the non-
gravid uterus. There are three distinct layers of muscle fibers are evident;
the Outer longitudinal; it follows a hood like arrangement over the fundus
and some fibers are continuous with the round ligaments, the Inner circular;
It is scanty and have sphincter like arrangement around the tubal orifices
and internal os and the Intermediate; It is the thickest and strongest layer
arranged in criss cross fashion through which the blood vessels run.
Apposition of two double curve muscle fibers give the figure of ‘8’ form,
Thus when the muscles contract, they occlude the blood vessels running
through the fibers and hence called living ligature (Figs 1 and 2) (Antony
et al., 2016).
Figure (1): Schematic presentation of the longitudinal, oblique and circular

muscle fibers of the pregnant uterus.
5
Figure (2) A and B: (A) Marked elongation of The muscle fibers during
pregnancy, (B) Blood Vessels in between interlacing muscle fibers.
The uterine enlargement is not a symmetrical one; the fundus

enlarges more than the body, it is evident by the low down attachment of
the round ligaments or insertion of the uterine end of the Fallopian tubes at
term. The Shape of non-pregnant uterus is pyriform which is maintained in
early months then it becomes globular at 12 weeks and as the uterus
enlarges, the shape once more becomes pyriform or ovoid by 28 weeks and
changes to spherical beyond 36th week (see Fig. 3) (Antony et al., 2016).
Figure (3): The level of fundus uteri at different Weeks; Note the change of
uterine shape.
The normal anteverted position of the uterus is exaggerated up to 8

weeks. Thus, the enlarged uterus may lie on the bladder rendering it
6
incapable of filling, clinically evident by frequency of micturition.

Afterwards, it becomes erect; the long axis of the uterus conforms more or
less to the axis of the inlet (Konar, 2015).
As the uterus enlarges to occupy the abdominal cavity, it usually

rotates on its long axis to the right (dextrorotation). This is due to the
occupation of the recto sigmoid in the left posterior quadrant of the pelvis.
This makes the anterior surface of the uterus to turn to the right and brings
the left cornu closer to the abdominal wall. The cervix, as a result, is
deviated to the left side (levorotation) bringing it closer to the ureter
(Konar, 2015).
Whereas in the non-pregnant state, the blood supply to the uterus is

mainly through the uterine and least through the ovarian but in the pregnant
state, the latter carries as much the blood as the former also there is marked
spiraling of the arteries reaching the maximum at 20 weeks; thereafter, they
straighten out. Doppler velocimetry has shown uterine artery diameter
becomes double and blood flow increases by eight fold at 20 weeks of
pregnancy, This vasodilatation is mainly due to estradiol and progesterone
also the veins become dilated and are valve less and numerous lymphatic
channels open up , these vascular changes are most pronounced at the
placental site (Antony et al., 2016).
During normal pregnancy a large network of new vessels in the

uterus is created by a direct angiogenic effect of human chorionic
gonadotrophin, hCG. Moreover, the existing uterine vessels dilate and
allow a substantial increase in blood flow to meet the increased
requirements of the fetus and placenta. These physiological changes of
maternal spiral arteries occur by cyto trophoblastic invasion of the
placental bed, which destroys and replaces their media layer. As a result,
7
first the intra decidual and later the intramyometrial portions of the spiral
arteries convert to non-muscular, dilated, low-resistance uteroplacental
vessels with markedly increased blood flow. Dramatic regressive changes
must occur after delivery. From histological studies we know that normal
involuted placental bed is characterized by a disappearance of trophoblasts
and completely thrombosed spiral arteries (Konar, 2015).
During the first trimester, isthmus hypertrophies and elongates to

about 3 times its original length and becomes softer and with advancing
pregnancy beyond 12 weeks, it progressively unfolds from above
downwards until it is incorporated into the uterine cavity and also there is
hypertrophy and hyperplasia of the elastic and connective tissues of the
cervical stroma, Fluids accumulate inside and in between the fibers.
Vascularity is increased specially beneath the squamous epithelium of the
portio vaginalis which is responsible for its bluish coloration (Antony et
al., 2016).
Physiology Of Uterine Involution Postpartum
The postpartum period, also known as the puerperium, begins with

the delivery of the baby and placenta but the end of the postpartum period
is less well-defined, it is often considered the 6 to 8 weeks after delivery
because the effects of pregnancy on many systems have resolved by this
time and these systems have largely returned to their prepregnancy state;
However, all organ systems do not return to baseline within this period and
the return to baseline is not necessarily linear over time, In some studies,
women are considered postpartum for as long as 12 months after delivery
(Cunningham et al., 2014).
8
Most of the physiologic changes in pregnancy will have returned to

their pre-pregnancy state by 6 weeks postpartum1, however, many of the
cardiovascular changes and psychological changes may persist for many
more months and some such as changes in the pelvic musculature and
cardiac remodeling will last for years (Kansky et al., 2016).
Immediately after delivery of the placenta, the uterus begins to

return to its non-pregnant size and condition, a process termed uterine
involution, the rapid uterine involution is driven primarily by the action of
endogenous or synthetic oxytocin. the uterine involution is defined by the
changing indices of the uterine size, the uterine cavity inserts, and the
uterine artery flow (Paliulyte et al., 2017).
A main characteristic of the puerperium is this uterine involution,

an extremely dynamic process of physiological transformation of the
uterus involving the myometrium, decidua and uterine arteries. The uterine
dimensions diminish progressively and substantially during the
puerperium (Paliulyte et al., 2017)
After delivery, the fundus is normally firm, nontender, globular,

and located midway between the symphysis pubis and umbilicus. In the
next 12 hours, it rises to just above or below the umbilicus, then recedes by
approximately 1 cm/day to again lie midway between the symphysis pubis
and umbilicus by the end of the first postpartum week. It is not palpable
abdominally by two weeks postpartum and attains its normal no pregnant
size by six to eight weeks postpartum. This process is modestly affected by
predelivery uterine over distention, Multiparity, and cesarean delivery (the
uterus is slightly larger in these cases), and by breastfeeding (the uterus is
slightly smaller in women who are breastfeeding). The weight of the uterus
9
decreases from approximately 1000 g immediately postpartum to 60 g six

to eight weeks later (Kansky et al., 2016).
The specific time course of uterine involution has not been fully
elucidated, but within 2 weeks after birth, the uterus has usually returned
to the pelvis, and by 6 weeks, it is usually normal size, as estimated by
palpation and the gross anatomic and histologic characteristics of the
involution process are based on the study of autopsy, hysterectomy, and
endometrial biopsy specimens (Antony et al., 2016). The decrease in the
size of the uterus and cervix during the puerperium has been demonstrated
with serial magnetic resonance imaging, serial sonography and computed
tomography (Kristoschek et al., 2017).
When the infant has been born and the placenta expelled, two
physiological lifesaving processes occur: myo- tamponade; Contraction
and retraction of the interlacing myometrial muscle bundles constricts the
intramyometrial vessels and impedes blood flow, which is the major
mechanism preventing hemorrhage at the placental site and In addition,
thrombo-tamponade large vessels at the placental site thrombose, which is
a secondary hemostatic mechanism for preventing blood loss. The aim of
these initial processes, known as the “physiological sutures” or “living
ligatures” (Baskett, 2000), is to prevent blood loss from the torn vessels of
the placental bed and Inadequate myometrial contraction will result in
atony (ie, a soft, boggy uterus), which is the most common cause of early
postpartum hemorrhage (Berens et al., 2017).
After delivery there is a rapidly decreasing endometrial surface area

facilitates placental shearing at the decidual layer. The average diameter of
the placenta is 18 cm; in the immediate postpartum uterus, the average
10
diameter of the site of placental attachment measures 9 cm (Antony et al.,

2016).
Concomitant with the changes of the uterus, the uterine cavity with
the placental bed goes through a marked process of involution as the
decidua is divided into a basal, a spongy and a superficial layer. The
separation of the placenta and membranes generally occurs in the spongy
layer, although the level varies (Konar, 2015). Already in 1931 Williams
wrote concerning the line of separation of the placenta and membranes:
“While separation generally occurs in the spongy layer, the line is very
irregular so that in places a thick layer of decidua is retained, in others only
a few layers of cells remain, while in still others the muscularis is
practically bare” (Mulic-Lutvica, 2017).
The initially remaining spongy and superficial layers of the

decidua, including utero placental decidual arteries often infiltrated with
blood, undergo necrosis and are cast off. The basal layer close to the
myometrium remains in the cavity and serves as a cell source from which
a new endometrium is regenerated (Mori et al., 2016)
While the decidual necrosis begins from the first day, on the other
hand, the immediate inflammatory cells polymorph nuclear leukocytes and
lymphocytes infiltrate the placental site a reaction that extends into the
endometrium and superficial myometrium and persists for about 10 days,
presumably serving as an antibacterial barrier. By the seventh day, a well-
demarcated zone can be seen between necrotic and viable tissue, The
Vessels in the placental site are characterized during the first 8 days by
thrombosis, hyalinization, and endophlebitis in the veins, and by
hyalinization and obliterative fibrinoid endarteritis in the arteries (Antony
et al., 2016).
11
An area of viable decidua remains between the necrotic slough and

the deeper endo-myometrium. The non-necrotic decidual cells participate
in the reconstruction of the endometrium Sharman, and by the sixth week,
decidual cells are rare. The leukocyte response diminishes rapidly after day
10, and plasma cells are seen for the first time. The plasma cell and
lymphocyte response may last as long as several months (Mori et al.,
2016).
The postpartum endometrium regenerates at a rapid pace; at day 7

postpartum, endometrial glands are already formed, and by day 16, the
endometrial is completely restored, By the 7th day there is evidence of the
regeneration of endometrial glands, by the end of the first week there is
evidence of the regeneration of endometrial stroma and as evidenced by
endometrial biopsies the endometrium lining is almost fully restored
throughout the uterine cavity by the postpartum day 16 with the exception
of the placental bed site. Which takes up to 6 weeks for complete
disappearance Moreover, the duration of puerperal lochia may be up to 60
days in 13% of women (Mulic-Lutvica, 2017).
Lochia
Normal shedding of blood and decidua is referred to as lochia rubra

(red/red-brown) and lasts for the first few days following delivery. Vaginal
discharge then becomes increasingly watery, called lochia serosa (pinkish
brown), which lasts for two to three weeks. Ultimately, the discharge turns
yellowish white, the lochia alba. Microscopically, lochia consists of serous
exudate, erythrocytes, leukocytes, decidua, epithelial cells, and bacteria
(Berens et al., 2017). Frequently, there is a sudden but transient increase
in uterine bleeding between 7 and 14 days postpartum. This corresponds to
12
the slough of the scar over the site of placental attachment. Myometrial
vessels of greater than 5 mm in diameter are present for up to 2 weeks
postpartum, which accounts for the dramatic bleeding that can occur with
this phenomenon. Although it can be profuse, this bleeding episode is
usually self-limited, requiring nothing more than reassurance of them
patient. If it does not subside within 1 or 2 hours, the patient should be
evaluated for possible retained placental tissue (Fletcher et al., 2012).
The total volume of postpartum lochia secretion is 200 to 500 mL,

which is discharged over a mean duration of one month. Up to 15 percent
of women continue to pass lochia for six to eight weeks, the time of the
standard postpartum visit. The duration of lochia does not appear to be
related to lactation or to the use of either estrogen-containing or
progesterone-only contraceptives, but women with bleeding diatheses may
be prone to longer duration of passing lochia (Berens et al., 2017).
The Cervix
After delivery, the cervix is soft and floppy. Small lacerations can
be found at the margins of the external os. The cervix remains 2 to 3 cm
dilated for the first few postpartum days and is less than 1 cm dilated at one
week. The external os never resumes its pregravid shape; the small,
smooth, regular circular opening of the nulligravida becomes a large,
transverse, stellate slit after childbirth. Histologically, the cervix does not
return to baseline for up to three to four month after delivery (Berens et
al., 2017).
13
Figure (4): Parous and nonparous cervix. (top) Normal nulligravid cervix: The
external os is a small, smooth circular opening. (bottom) Normal parous cervix: The
external os is a large, transverse, stellate slit.
During pregnancy, the cervical epithelium increases in thickness,

and the cervical glands show both hyperplasia and hypertrophy. Within the
stroma, a distinct decidual reaction occurs. These changes are accompanied
by a substantial increase in the vascularity of the cervix. Regression of the
cervical epithelium begins within the first 4 days after delivery, and by the
end of the first week, edema and hemorrhage within the cervix are minimal.
Vascular hypertrophy and hyperplasia persist throughout the first week
postpartum. By 6 weeks postpartum, most of the antepartum changes have
resolved, although round cell infiltration and some edema may persist for
several months (Antony et al., 2016).
14
Uterine Pathophysiology During The Puerperium
The process of uterine involution, which is one of the main

characteristics of the postpartum period, may be affected in pathological
conditions such as uterine infection and hemorrhage. Both are main causes
of maternal death worldwide; therefore, a correct diagnosis is of paramount
importance (Kristoschek et al., 2017).
- Postpartum hemorrhage:
Vaginal bleeding that persists for more than approximately eight

weeks after delivery is unusual and may be due to infection, retained
products of conception, a bleeding diathesis, or, rarely, choriocarcinoma or
a uterine vascular anomaly, as well as other causes. A temporary increase
in bleeding at this time may represent menses; in such cases, bleeding
should stop within a few days. New bleeding several weeks after delivery
could also be related to a new pregnancy (Berens et al., 2017).
Primary postpartum haemorrhage (PPH) is traditionally defined as

the loss of at least 500 ml of blood from the lower genital tract within 24
hours of delivery or any blood loss less than 500 ml resulting in maternal
haemodynamic compromise.1–4 Although the most common cause of
primary PPH is uterine atony, care must be taken to exclude retained
products of conception (placenta and membranes) or intrauterine blood
clots as an additional or primary cause.4 Bedside ultrasound scanning can
therefore be a useful diagnostic adjunct to clinical examination; clearly,
‘off-ward’ ultrasound assessment is rarely indicated in this emergency
setting (Üçyiğit and Johns, 2016).
15
while Secondary postpartum hemorrhage is any abnormal or

excessive bleeding from the birth canal occurring between 24 hours and 12
weeks postnatally, and occurring in 1-2% of deliveries, Most studies report
peak incidence is at one to two weeks postpartum (Dossou et al., 2015).
The most common causes of secondary PPH are (Edhi et al.,

2013):
 Retained products of conception
 Sub involution of the placental bed that may be idiopathic, and/or
 Infection (endometritis)
Rare causes include:
 Inherited or acquired bleeding diatheses
 Pseudo aneurysm of the uterine artery
 Arteriovenous malformations
 Choriocarcinoma
 Undiagnosed carcinoma of the cervix
 Adenomyosis
 Infected polyp or submucosal fibroid
 Uterine diverticulum
 Excessive bleeding with resumption of menses
 Hypoestrogenism
 Dehiscence of a cesarean scar.
(Berens et al., 2017)
16
Vascular abnormalities of the uterus have recently been described

as possibly more common causes of severe SPH than previously thought
(Kelly et al, 2003). True arteriovenous (AV) malformations are rare errors
of morphogenesis, which do not regress spontaneously (Müngen, 2003).
Acquired AV abnormalities are associated with trauma after previous
intrauterine procedures, RPT, infection or malignancy. It has been
hypothesized that some viable trophoblast cells may remain in “placental
polyps”, and vessels below the RPT may show persistent dilatation.
Arteriovenous malformation of the uterus associated with secondary
postpartum hemorrhage (Mulic-Lutvia, 2017).
The risk factors for PPH may be a previous history of secondary

PPH appears to predispose to a recurrence, as with primary PPH. A history
of primary PPH is a risk factor for severe secondary PPH (Newsome et al.,
2017).
Several predisposing factors for SPH have been established:

prolonged third stage of labor, incomplete placenta and/or membranes
passed at birth, PPH and maternal smoking (Marchant et al., 2006).
Vaginal bleeding in excess of what is expected is the presenting

symptom in all patients. Bleeding may be accompanied by pelvic pain,
fever, and/or uterine tenderness. These clinical findings are nonspecific;
moreover, it is normal to have some postpartum bleeding and discomfort
(Newsome et al., 2017).
In developing countries, SPH is still a major contributor to maternal

death. In developed countries, more than half of women admitted to
hospital with SPH undergo uterine surgical evacuation. Invasive treatment
may be a major threat to mothers and carries a risk of complications, and
17
Also late sequelae related to surgical treatment of SPH may influence the
reproductive health of women. If curettage damages the endometrium 1 to
4 weeks post-partum, the endometrium may fail to regenerate, leading to
Asherman’s syndrome (Mulic-Lutvia, 2007).
In a Cochrane Review, Alexander et al. (2002) identified 45

papers on the management of SPH and concluded that little information is
available from randomized trials to guide clinicians in the management of
this condition. Since the causes of SPH may vary the best treatment options
should be chosen according to the underlying cause of bleeding. However,
an essential problem is that the underlying cause of SPH often is unknown
and that clinical or ultrasonic diagnosis of RPT, which is the indication for
surgical treatment, is still a controversial issue. The decision whether to
perform uterine evacuation for RPT depending on both clinical finding and
ability visualize retained placenta by ultrasound, although prompt
curettage seems necessary in many cases it usually does not remove
identifiable placental tissues moreover it is more likely traumatize the
implantation site and incite more bleeding.
Whether to initially manage secondary PPH medically or surgically

is still a relatively unstudied aspect of the care of these patients. No data
from randomized trials are available to guide management. Surgical
procedures (dilation and curettage, suction curettage) are often effective
when medical management fails, even if retained placental or membrane
fragments cannot be identified sonographically. Selective arterial
embolization has been effective for controlling severe bleeding in high-risk
patients, who can be refractory to uterotonic drugs or uterine curettage. If
percutaneous therapy fails, hysterectomy may be required (Mulic-Lutvia,
2007).
18
Retained Placental Tissues (RPT):
Normal detachment of the placenta requires the presence of a

normal spongy decidua Vera, where shearing of the placenta from the
myometrium occurs. Defective decidua, which can be scanty or completely
absent in some women, is a predisposing factor for abnormal attachment
of the placenta, implying abnormal growth into the myometrium, and thus
even for RPT in forthcoming pregnancie. Necrosis and deposition of fibrin
in RPT can form a “placental polyp”, which is usually larger than the
placental remnant (Perlman and Carusi, 2019).
Retained placental tissue (RPT) in the uterine cavity postpartum is

associated with a high risk of excessive bleeding. Either; Primary
postpartum hemorrhage (PPH), within the first 24 hours postpartum and
/or Secondary Postpartum hemorrhage (SPH) requires manual or
instrumental evacuation of the uterine cavity, also invasive treatment
carries a risk of complications and a major threat to mothers (Nikolajsen
et al., 2013).
The diagnosis is clinical, Histological confirmation of RPT is

obtained in only 30-50% of these cases. Moreover, puerperal curettage may
traumatize the uterine wall and provoke additional bleeding, which can be
life-threatening and require hysterectomy. Perforation of the uterus after
curettage occurs in 3% and hysterectomy in about 1% (Urner et al., 2014).
A published audit of 200 cases concerning puerperal curettage showed that
8.5% of patients experienced major morbidity and 7% required a repeat
procedure with further morbidity (Pather et al., 2005).
Carlan et al., (1997) performed manual exploration of the cavity in

131 asymptomatic women 5 min after placental delivery and within 2
19
minutes after an US examination. They found that 24 of 131(18.8%)

women had documented evidence of RPT. In a study of 24750 deliveries,
clinically significant RPT requiring manual evacuation was found in 0.6%
of the women (Tandberg et al, 1999).
Suspicion of RPT usually arises when SPH, lower abdominal pain

and/or postpartum fever occur or if an incomplete placenta is suspected at
delivery (Mulic-Lutvica, 2007).
Surgical procedures (dilation and curettage, suction curettage) are

directed at evacuation of retained products of conception, which are more
common after vaginal than cesarean delivery and when a vascularized
endometrial mass is noted on color Doppler, Ideally; curettage is
performed under ultrasound guidance, This is likely to reduce the rate of
perforation, allow identification of placental tissue, and confirm that this
tissue has been evacuated (Guarino et al., 2015).
Suction curettage should be employed when bleeding is over 500

mL and is not controlled by medical measures. The size of the suction
cannula is determined by the size of the uterus. The diameter of the cannula
is usually chosen according to the uterine size by gestational age (eg, a 12
mm cannula for a uterus of 12 weeks size) with a minimum diameter of 10
mm and a maximum diameter of 16 mm (Yancey et al., 2016).
Uterine perforation and formation of intrauterine adhesions are the

major complications of surgery. In the series described above, perforation
occurred in 3 percent of cases (Guarino et al., 2015).
20
Sub Involution Of The Placental Site
Sub involution is an abnormality in the involution of the uterus in

which the rate of involution is lesser than normal, Sub involution of the
placental site is a likely under recognized cause of postpartum hemorrhage
because it can be diagnosed only by pathologic analysis after hysterectomy
or sufficient uterine curettage (Weydert and Benda, 2006).
Sub involution of the placental site is characterized by the abnormal

persistence of low-resistance widely dilated uteroplacental arteries in the
absence of substantial amounts of retained products of conception. There
may be an immunologic basis for this condition through a common
mediator that causes these vessels to regress prematurely in eclampsia
(Petrovitch et al., 2009).
Causes of Subinvolution are:
 Cesarian Section - this causes delayed healing of the incised uterine

muscles.
 If the uterus is not completely empty after the childbirth and there is
retained products of conception like bits of the placenta or
membranes, involution may be hampered. These can also form the
focus of infection and cause postpartum infection.
 Prolonged labour exhausts the uterine muscles and delays healing,

leading to subinvolution.
 Multiple pregnancies like twin or triplet pregnancies cause excessive

stretching of the muscles fibres and these may take longer than
normal to come back to the normal state.
21
 Secondary infection - Postpertum Infection can delay healing and

involution.
 If the bladder is not completely emptied, the uterus may appear to be

at a higher level than normal and a wrong diagnosis of subinvolution
made. The uterus should always be measured after the bladder has
been emptied.
(Weydert and Benda, 2006)
Signs and Symptoms of Subinvolution
The main sign of subinvolution is delayed decrease in the size of

the uterine height. Lochia Rubra is present for a longer time than normal.
Infection is indicated by a foul smell of the lochia (Petrovitch et al., 2009).
Treatment of Subinvolution
- Treatment is according to the cause.

 Chronic diseases: Chronic diseases like tuberculosis can cause
subinvolution. The tuberculous toxins appear to have a special
affinity for the ovary and the uterine endometrium.
 Nutritional Causes: Severe starvation as seen in malabsorption

syndromes and during war and famine can cause subinvolution
after childbirth.
 Infection: Postprtum infeciton is a very common cause of

subinvolution.
(Voorhorst et al., 2013)
22
Endometritis:
Although a low-grade fever is expected in the first 24 hours after

vaginal delivery or cesarean section, fever after this period is suspicious
for endometrial infection. Endometritis is more common after cesarean
section, with rates up to 30 times higher than that after spontaneous vaginal
delivery (Mulic-Lutvica and Axelsson, 2007). The rates are higher when
prophylactic antibiotics are not used, such as for emergent cesarean
sections or some cases of therapeutic abortions (Olsen et al., 2010).
If bleeding is not massive and fever, uterine tenderness, and/or a

malodorous discharge are present, then endometritis should be suspected.
Under these circumstances, a broad-spectrum antibiotic therapy is
prescribed. However, some clinicians administer antibiotics to all patients
with secondary PPH, including those without obvious signs of infection.
Rare, but potentially lethal causes of endometritis include Clostridium
sordellii, Clostridium perfringens, and streptococcal or staphylococcal
toxic shock syndrome (Chibueze et al., 2015).
Endometritis and Postpartum Infection Endometritis, or infection

of the uterine decidua, is the most common cause of postpartum fever.
Endometritis is a clinical diagnosis, but uterine imaging is sometimes
requested to guide therapeutic decisions. Typically, endometritis is treated
with broad spectrum antibiotics, but if RPOC, infected hematoma, or
uterine abscess are present, evacuation may be required (Olsen et al.,
2010).
23
Arteriovenous Malformations (AVMs)
Since the first report of a uterine AVM almost 90 years ago

(Dubreuil and Loubat, 1926), these rare pelvic lesions are now
increasingly reported in the literature, with over 200 cases (Üçyiğit and
Johns, 2017).
Classically an acquired anomaly, uterine AVMs are most

commonly associated with trophoblastic disease, pelvic surgery (e.g.
myomectomy), endometrial curettage, uterine malignancy and caesarean
scar pregnancy. A congenital aetiology has been postulated, particularly in
cases where there is multi-organ involvement and the presence of multiple
AVMs. They are most prevalent in women of reproductive age, rarely
occurring in the nulligravid. Thus, it has been hypothesised that pregnancy
contributes to the pathogenesis of uterine AVMs (Kelly et al., 2003),
where necrosis of chorionic villi leads to the incorporation of venous
sinuses into areas of myometrial scarring (Üçyiğit and Johns, 2017).
Uterine AVMs can present with either primary or secondary PPH,

and rarely, a pulsatile pelvic mass. The volume of blood loss can be
extensive and swift, leading to rapid hemodynamic compromise. The
possibility of a vascular malformation in postpartum patients may delay
curettage for fear of provoking hemorrhage, despite a lack of definitive
evidence to suggest this as a complication. Conservative therapy and
observation have been suggested for stable patients with a suspected
vascular malformation, and embolization of the feeding vessel and less
often surgical excision of the lesion, or hysterectomy that is recommended
only for unstable patients (Hashim and Nawawi, 2013).
24
UTERINE EVALUATION DURING NORMAL

AND ABNORMAL PUERPERIUM
Clinically uterine involution is associated with a midline,

intermittent, lower abdominal and back pain are common postpartum and
believed to be due to hypertonic uterine contractions. Typically, the pain is
exacerbated by breastfeeding and is worse in multiparas than primiparous.
The pain usually resolves by the end of the first postpartum week
(Cunningham et al., 2014).
The knowledge about postpartum changes in the uterus has mainly

been based on clinical examinations as well as on histological studies from
the end of the 19th century and the early part of the 20th century when
maternal death during the puerperium was common place. The involution
of the uterus, as a main characteristic of the puerperium was previously be
followed by simple anthropometry by assessment of the symphysis-fundus
distance over the puerperal period assessed by palpation but this can be
imprecise in obese women and in women with uterine myoma (Mulic-
Lutvica, 2012).
In a study that compared Postpartum manual and sonographic

assessment of uterine involution was performed in 120 patients following
vaginal and cesarean delivery with an attempt to build a database of
changes in uterine dimensions the Conclusion was; Within 3 days after
delivery, patients particularly those having had a cesarean section, should
undergo uterine sonographic scanning and manual palpation to evaluate
involution and presence of blood in the uterine cavity (Shalev et al., 2002).
25
In another study the rans abdominal sonography was suitable for

examination of the uterus during the first 14 days postpartum but from day
28 the transvaginal route is preferable, The uterine body and position, as
well as the cavity, are easy to examine by ultrasound (Mulic-Lutvica A;
et al.,.2001). Although assessment of uterine size is routinely performed
in the early postnatal period, there is no evidence that uterine size is
predictive of complications (Berens et al., 2017).
Since the introduction of US in clinical practice by Ian Donald et

al. in 1958, the uterus became one of the first organs to be examined. The
term "ultrasound" refers to sound waves of a frequency greater than that
which the human ear can appreciate, namely frequencies greater than
20,000 cycles per second or Hertz (Hz). To obtain images of the pregnant
or non-pregnant pelvis, frequencies of 2 to 10 million Hertz (2 to 10
megahertz [MHz]) are typically required. Real-time imaging is the most
common sonographic technique used in obstetrics and gynecology.
Multiple individual B-mode gray-scale images are obtained and rapidly
displayed in succession, thereby creating a video of the area of interest over
time that can be used to evaluate its structure and some aspects of its
function. Real-time ultrasound is especially useful for imaging mobile
subjects, such as the fetus or heart, and for quickly viewing an organ from
different orientations (Berens et al., 2017).
However, only a few ultrasound studies have involved

investigations during the puerperium4–9. In the majority of previously
published studies, old compound scanners with poor image resolution were
used. The actual timing of measurements is rarely specified. Pathological
conditions were evaluated without knowledge of US images of the normal
puerperal uterus. Moreover, most studies from the 1980s were cross-
26
sectional and the examinations were most often restricted to the early
puerperium (Mulic‐Lutvica et al., 2001).
The high-resolution ultrasound equipment that is currently

available increases the role of ultrasonography in assessing the normal and
abnormal puerperal dynamics. Ultrasonography is a non-invasive, low cost
technique that is well accepted by patients (Kristoschek et al., 2017).
Ultrasound examination (including color and spectral flow

Doppler) of the uterus may detect the cause of bleeding and will help
exclude some potential bleeding sources in the differential diagnosis.
However, the postpartum uterus has a variable appearance on ultrasound
examination, and there is considerable overlap between normal postpartum
findings and findings associated with secondary bleeding. In both cases,
the uterus may be empty or contain gas, fluid, or echogenic material (De
Winter et al., 2017).
In a study of Serial ultrasound examinations of postpartum patients

showed that in 20% to 30%, there was some retained blood or tissue within
24 hours after delivery. By the fourth postpartum day, only about 8% of
patients showed endometrial cavity separation, a portion of which
eventually had abnormal postpartum bleeding because of retained placental
tissue.8 Ultrasound may be helpful in the management of abnormal
postpartum bleeding. The empty uterus with a clear midline echo can often
be distinguished from the uterine cavity expanded by clot (sonolucent) or
retained tissue (echo dense) (Antony et al., 2016).
As regard to Doppler ultrasound; it has been used to measure flow

resistance indices of the uterine arteries during the normal menstrual cycle,
during both normal and pathological pregnancies and during labor. High
27
diastolic flow velocities in combination with a disappearance of the early

diastolic notch are the main characteristics of the uterine artery Doppler
flow pattern from gestational week 20-26. They reflect the physiological
conversion from a high (non-pregnant) to a low (pregnant) resistance state.
How rapidly these physiological changes return to the nonpregnant state is
a controversial issue (Mulic-Lutvica, 2007).
A small number of Doppler US studies has been published

regarding the hemodynamic events that occur during the puerperium, and
the results have been contradictory. By color Doppler, a hypervascular area
with turbulent flow at the implantation site representing the
“peritrophoblastic flow” is observed in early pregnancy. Doppler studies
of the post-abortion appearance of the uterus showed that the hyper
vascularity disappears gradually and its regression is prolonged in the
presence of retained products of conception. Numerous papers about this
hyper vascular area have recently been published but only one focused on
colour Doppler during the normal puerperium. There is confusion as to
how US findings of such a hyper vascular area should be interpreted as this
area was observed in both normal and pathological puerperium (Mulic-
Lutvica, 2007).
28
NORMAL POSTPARTUM FINDINGS ON

ULTRASOUND
Despite numerous histological and ultrasonographic studies
assessing uterine involution, there are conflicting data describing the
typical ultrasound appearances of the uterine cavity and its contents
postpartum, and also the relevance of such findings to clinical practice
(Üçyiğit and Johns, 2017).
The postpartum uterus has a variable appearance on ultrasound

examination, and there is considerable overlap between normal postpartum
findings and findings associated with secondary bleeding. In both cases,
the uterus may be empty or contain gas, fluid, or echogenic material
It would be useful to know the normal US appearance of the uterus

throughout the entire puerperal period in order to improve our ability to
distinguish puerperal pathology from normal conditions and thus avoid
unnecessary invasive procedures. Moreover, the knowledge obtained
through US examinations can help us to better understand the physiology
of the puerperium (Mulic-Lutvica et al., 2001).
There is a great variability between different studies about the best

indicator of the uterine involution process some used the uterine Length,
width, AP diameter, area and volume of the uterus have all been used, as
well as thickness of the uterine wall (Mulic-Lutvica and Axelsson, 2007).
As regards the uterine cavity, there is a notable lack of studies

during the normal puerperium and the results from the few studies are
contradictory. No evidence was found that any form of anthropometric
29
assessment of uterine involution in the early postnatal period has either

preventative or predictive value. Research on this topic is long overdue
(Mulic-Lutvica and Axelsson, 2007).
There is also disagreement concerning the influence on the

involution process of parity breast-feeding or the infant’s birth weight.
There are also confusing data about the presence of gas fluid or echogenic
masses in the cavity during the normal puerperium (Mulic-Lutvica et al.,
2001).
A more up to date assessment of the postpartum uterus, not only

assessing the anteroposterior (AP) diameter of the uterus but also the
endometrial thickness suggests that mode of delivery can affect the rate of
uterine involution; for example, the decrease in endometrial thickness over
the second to sixth week postpartum following a term vaginal delivery was
found to be significantly greater than that following term caesarean section.
The findings were also similar when comparing gestational age, whereby
the decrease in the AP diameter of the uterus was less after a preterm
delivery versus a term delivery. Although based on a small number of
cases, this study supports the theory that the process of uterine involution
will vary with both mode and timing of delivery (Mulic-Lutvica et al.,
2001).
To aid understanding of the physiological and pathological

characteristics of the postpartum uterus, ultra-sonographic assessment of
the uterine cavity can be broadly divided into two categories: (a) the
immediate post-partum period, i.e. within the first 24 hours and (b) 24
hours post-delivery through to the end of the puerperium.
30
Ultrasound Appearances Immediately Postpartum

(Within 24 Hours)
In a prospective observational study of 94 women, Deans and

Dietz, (2006) sought to establish if there was any correlation between
transabdominal ultrasound findings and patient morbidity.15 In the first 24
hours after delivery, ultrasound revealed an unexpectedly large volume of
echogenic material within the uterine cavity, in particular within the lower
segment of the uterus, where mean volumes were as great as 54.8 cm3.
However, when followed up for symptomatology, there was no correlation
between the presence of this material and the development of postpartum
morbidity, such as pyrexia, PPH or prolonged hospital stay. This suggests
that the presence of large volumes of intrauterine echogenic material in the
first day post-delivery can be accepted as normal (Üçyiğit and Johns,
2016).
Similarly, an American study undertook immediate

ultrasonographic assessment following placental delivery but with
concomitant manual exploration and sponge curettage of the uterine cavity,
within 2 minutes of the scan (Carlan et al., 1997). Following histological
assessment of the intrauterine material, the sensitivity, specificity, positive
and negative predictive value of ultrasound in detecting retained products
in their study was 44%, 92%, 58% and 87%, respectively. Of those patients
with histologically confirmed retained products of conception, the majority
in fact had a normal endometrial cavity on ultrasound scan (37.5%). An
echogenic mass was seen in 25%, a heterogeneous mixed density mass in
21% and intrauterine fluid alone was visible in 16.6%. The vascularity of
these intrauterine masses was, however, not assessed. Thus, it can be
concluded that in the absence of color Doppler assessment, the appearances
31
of retained products immediately following delivery are highly variable

and cannot be correlated with a need for intervention (Üçyiğit and Johns,
2016).
A prospective observational study of 30 patients assessed the

ultrasonographic appearances of the uterine cavity following lower
segment caesarean section (LSCS) at 1 hour, 3 hours and again at 24 hours
post-delivery (Koskas et al., 2008). Unsurprisingly, as the operating
surgeon undertook systematic manual examination of the uterine cavity
following delivery of the placenta in each case, the incidence of
intrauterine material visible on scan was low (3%, n = 1). This particular
patient did not exhibit postpartum pathology, and once again questions the
significance and clinical relevance of such findings (Üçyiğit and Johns,
2016).
Ultrasound Appearances After The First 24 Hours

Postpartum
There are observations suggest that the presence of echogenic

material can be a normal finding and need not change clinical management
in patients who do not have heavy bleeding or signs of uterine infection
and accumulation of fluid and debris in the uterine cavity is a common and
insignificant finding of the involuting uterus, which is located in the
cervical area in the early puerperium and in the whole uterine cavity in the
middle part of the puerperium. However, in women with fever and/or
bleeding, an echogenic mass may represent retained products of conception
The following representative studies are for the normal

sonographic appearance of the postpartum uterus:
32
In the commonly cited study by Edwards and Ellwood, (2000), 40

women were systematically scanned at weekly intervals postpartum,
starting from day 7 up until day 21. They observed that in women with
normal postpartum bleeding, there was an echogenic mass in 51% on day
7, in 21% on day 14 and in 6% on day 21, and found no difference in either
the heaviness or bleeding duration between women with and without an
echogenic mass at each of these three scans. Thus, they hypothesise that
either ‘an echogenic mass does not always represent retained products of
conception, or that products of conception are commonly retained and are
therefore of little clinical significance in many cases’. However, there is no
evidence that Doppler assessments of these products were undertaken, nor
is there any clarification by the authors as to whether the description of an
echogenic mass also includes mixed-echo patterns, a finding which other
studies have suggested is an insignificant postpartum occurence.18 Care
must therefore be taken to interpret ultrasound scan findings in this clinical
context; the specific finding of an echogenic mass in the setting of
secondary PPH is likely to be associated with retained placental tissue and
requires surgical intervention, whereas mixed-echo patterns are not, and
can be managed expectantly, with early resolution of symptoms (Mulic-
Lutvica and Axelsson, 2006).
Van Den Bosch's group evaluated the application of colour Doppler

in aiding identification of placental remnants (Van den Bosch et al., 2002).
Their cross-sectional study of 385 postnatal women revealed areas of
enhanced vascularity in 32 women (8.3%), and 26 women (6.75%) had
retained placental products on scan. Although no comment was made
regarding patient morbidity, a high incidence of histological confirmation
was obtained following surgical curettage (19 of 20 cases), suggesting that
the use of colour Doppler may be of practical diagnostic value. Figures 5
33
to 9 demonstrate the use of color Doppler in aiding the diagnosis of

retained products of conception, later confirmed on histological analysis.
Figure (5): Echogenic mass within the endometrial cavity seen in the sagittal plane
on transvaginal scan 6 weeks post vaginal delivery (Üçyiğit and Johns, 2016).
Figure (6): Application of colour Doppler demonstrates trophoblastic blood flow

to the region of the echogenic mass, aiding diagnosis of retained products of
conception (Üçyiğit and Johns, 2016).
34
Figure (7): Echogenic mass seen within the lower uterine segment in the sagittal
plane on transvaginal scan performed in a symptomatic patient 8 weeks post
vaginal delivery (Üçyiğit and Johns, 2016).
Figure (8): Echogenic mass within the lower uterine segment in the same patient
as seen in the transverse plane on transvaginal scan (Üçyiğit and Johns, 2016).
35
Figure (9): Application of colour Doppler demonstrates trophoblastic blood flow

to the region of the echogenic mass in the transverse plane on transvaginal scan
aiding diagnosis of retained products of conception (Üçyiğit and Johns, 2016).
[
In a prospective, longitudinal study that performed ultrasound

examinations on postpartum days 1, 3, 7, 14, 28, and 56 in 42 women with
uncomplicated vaginal term deliveries, The first four examinations were
performed trans abdominally and the last two trans vaginally, The
involution process of the uterus was assessed by measuring the
anteroposterior diameter of the uterus and uterine cavity. The maximum
anteroposterior diameter of the uterus diminished substantially and
progressively from 92.0 mm on day 1 postpartum to 38.9 mm on day 56.
The maximum anteroposterior diameter of the uterine cavity diminished
from 15.8 mm on day 1 to 4.0 mm on day 56. However, the anteroposterior
diameter of the uterine cavity, 5 cm from the fundus, typically increased
on days 7 and 14 postpartum. The uterus was most often empty in the early
puerperium (days 1 and 3), fluid and debris were seen in the entire cavity
in the middle part of the puerperium (day 14), while the late puerperium
(days 28 and 56) was characterized by an empty cavity that appeared as a
thin white line (Mulic-Lutvica et al., 2001). Endometrial gas was
36
occasionally seen. Gas in the uterine cavity may be seen after cesarean
delivery or after manual evacuation of the placenta. No correlation was
found between the involution of the uterus and parity, breast-feeding and
the infant's birth weight (Al-Bdour et al., 2004).
In another study of 40 women who underwent ultrasound

examination 48 hours after vaginal delivery, 16 had intrauterine echogenic
material, which was not associated with the amount or duration of bleeding
(Sokol et al., 2004).
Figure (10): (A) Transabdominal sagittal greyscale image and (B)

transvaginal color Doppler image from a 35-year-old woman two weeks
postpartum with vaginal bleeding. Note the fluid and debris in the uterus.
The color Doppler image shows no flow within the debris. Courtesy of
Deborah Levine, MD. Graphic 73717 Version 4.0
37
In A longitudinal study of 300 women in the puerperium was

undertaken in an African population. That aimed to determine the influence
of parity on postpartum uterine diameters during involution; the uterine
diameters were larger in the multiparous group when compared with the
nulliparous group and further analysis revealed positive correlation
between parity and uterine diameters and uterine volume (Olayemi et al.,
2002).
In a Prospective longitudinal follow-up study of Four thousand one

hundred eighteen breast-feeding mothers to determine the relation between
infant breast-feeding practices and the duration of postpartum amenorrhea
in different populations; the study established that the breast-feeding
stimulus is strongly linked to the duration of postpartum amenorrhea
(WHO, 1998).
As regards morphological findings to postpartum uterine position;

the uterus usually rotates about 100–180° along the internal cervical os and
changes its position from a retroverted to an anteverted position during the
involution period, In 12.0% of cases the uterus remained in a retroverted
position after completed involution. On days 1 and 3 post-partum the uterus
had an angulated form, lying in a slightly retroverted position. The
angulation was situated just above the internal os. This position of the
uterus is probably due to a heavy corpus, a hypotonic lower segment in
combination with the supine position of the examined women (Mulic-
Lutvica, 2007).
38
Figure (11): The normal rotation process of the uterus during the
puerperium
Caesarean Section Associated Findings
With rising rates of caesarean section delivery, our understanding

of what are normal and abnormal post-caesarean ultrasound findings is
improving. Following an uncomplicated procedure, the uterine incision can
be seen as an iso- or hypoechoic region when compared with myometrium,
and when imaged in the sagittal plane on transvaginal scan, is centrally
located between the uterus and bladder. Depending on probe orientation,
the uterine sutures can be identified as linear or point-like hyperechoic foci,
and small haematomas (<15 mm) along the suture line can be considered
as normal (Rodgers et al., 2012).
If adequate haemostasis has not been achieved intraoperatively, the

immediate post-operative period may be complicated by the formation of
a ‘bladder flap’ haematoma. During a LSCS, the visceral peritoneum is
incised between the uterus and bladder, and reflected inferiorly. It is in this
space that a haematoma may form, and will be seen as a non-vascular mass
39
of mixed echogenicity, anterior to the uterus and posterior to the bladder,

and has been described as a ‘bladder flap’ haematoma in the literature
(Figures 7 and and88) (Rodgers et al., 2012).These may or may not be
contained by the overlying peritoneum, and in the latter scenario will lead
to the detection of haematoperitoneum on scan (Üçyiğit and Johns, 2016).
Ultrasound findings after caesarean section during the last ten years
the CS rate has been steadily rising and we can expect more placental
complications in forthcoming years. Caesarean section (CS) is one of the
leading predisposing factors for puerperal endometritis. The involution of
the uterus after CS has been studied but the results are inconclusive. The
majority of published studies were related to postoperative complications.
The US appearance of the uterine wound after CS has been sparsely studied
(Mulic-Lutvica and Axelsson, 2006).
By color Doppler, a hypervascular area with turbulent flow at the

implantation site representing the “peritrophoblastic flow” is observed in
early pregnancy. Doppler studies of the post-abortion appearance of the
uterus showed that the hypervascularity disappears gradually and its
regression is prolonged in the presence of retained products of conception.
Numerous papers about this hypervascular area have recently been
published but only one focused on colour Doppler during the normal
puerperium. There is confusion as to how US findings of such a
hypervascular area should be interpreted as this area was observed in both
normal and pathological puerperium (Mulic-Lutvica and Axelsson,
2006).
40
ULTRASOUND FINDING IN ABNORMAL

PUERPERIUM
As illustrated before Ultrasound examination (including color and
spectral flow Doppler) of the uterus may detect the cause of bleeding and
will help exclude some potential bleeding sources in the differential
diagnosis. However, the postpartum uterus has a variable appearance on
ultrasound examination, and there is considerable overlap between normal
postpartum findings (image 1) and findings associated with secondary
bleeding [22,23]. In both cases, the uterus may be empty or contain gas,
fluid, or echogenic material (Üçyiğit and Johns, 2016).
In a cohort study carried by Shaamash et al., (2007) on 265

women who were examined ultrasonographically on postpartum Days 1,
14, 42 following uncomplicated vaginal or cesarean deliveries. To
determine whether there is a relationship between the findings of routine
postpartum ultra-sonographic 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 ultra-sonographic scanning and clinical data in the
prediction of these complications. The study found that the presence of risk
factor(s) was significantly associated with uterine sub involution,
intrauterine echogenic/heterogeneous mass (IUM), heavy delayed
postpartum hemorrhage (PPH), and a need for uterine curettage. The study
concluded that 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 sub involution or the presence of an IUM.
41
Accordingly, it may be predicted which women will benefit from uterine

curettage in up to two-thirds of cases.
Retained Products Of Conception
In patients with SPH, ultrasound should help verify or rule out RPT.
Robinson and Malvern published the first descriptions of US images of
RPT in 1972 and 1973, respectively. These studies were performed with
old compound US equipment and showed a high rate of false positive
diagnoses. Similar results have been obtained with modern US equipment.
Published studies have demonstrated a varying sensitivity (42-94%) and
specificity (62-92%) for Gray-scale US diagnosis of RPT. As echogenic
masses have been found in asymptomatic women the previously held
opinion that an echogenic mass in the cavity represents RPT responsible
for postpartum bleeding has been challenged. Moreover, in the majority of
studies, distinction between an echogenic mass and a mixed echo pattern
is not well established and there is confusion as to how ultrasound images
of the intracavitary content should be described (Mulic-Lutvica, 2007).
The physiological involution of the uterus postpartum, involving

the uterine arteries and their branches at the placental site, may be delayed
in the presence of RPT in the uterine cavity. There is a shortage of
publications and knowledge concerning the association between uterine
artery Doppler flow resistance indices and RPT. Previously published
studies has focused on colour Doppler of the uterus and RPT. Despite the
fact that US technology has become more powerful with the introduction
of the transvaginal (TV) approach (and sonohysterography in combination
with Doppler modalities, demonstration of RPT is difficult and still
represents a clinical challenge (Mulic-Lutvica, 2007).
42
Vascularity of echogenic intracavitary material is a key finding as

vascularity on color Doppler suggests retained products whereas lack of
vascularity is consistent with blood clot, but does not exclude the presence
of retained necrotic (avascular) placental tissue. If no intracavitary mass,
endometrial fluid, or vascularity is seen and the endometrial thickness is
thin, retained products are not likely (Kamaya et al., 2009).
Retained products of conception have a variable and sometimes

nonspecific appearance on ultrasound. They often appear as a solid,
echogenic intracavitary mass that extends to the endometrium. However,
necrotic decidua and blood clots can mimic retained placental fragments.
Color and spectral Doppler showing high-velocity, low-resistance arterial
flow in the mass differentiates placental tissue from hematoma, but is not
always present in the retained tissue. In the absence of a mass, increased
vascularity in a thickened postpartum endometrium is also consistent with
retained placental tissue. Rarely, a focal morbidly adherent placenta
presents as secondary postpartum hemorrhage. Ultrasound findings include
a mass that extends into or beyond the myometrium. (See "Overview of the
postpartum period: Physiology, complications, and maternal care", section
on 'Findings on ultrasound' (De Winter et al., 2017).
43
Figure (12): 34-year-old woman with persistent vaginal bleeding 4 weeks

after uneventful vaginal delivery (retained products of conception). A,
Sagittal transvaginal ultrasound confirmed presence of echogenic material
(arrow) within endometrial cavity. Internal flow was noted with color
Doppler images (not shown).
https://www.ajronline.org/doi/full/10.2214/ajr.12.9637?mobileUi=0
Endometritis and intrauterine infection — Ultrasound findings are

often nonspecific in endometritis; the uterus may have a thickened,
heterogeneous endometrium or show common normal postpartum
findings, such as intracavitary debris, fluid, or gas. Infected retained
placental tissue/fetal membranes or a hematoma may also be present
(Berens et al., 2017).
A prospective, descriptive, observational study of 103 postpartum

women was conducted by Mulic-Lutvica and Axelsson, (2007), To
measure anteroposterior (AP) diameters, and to describe qualitative
findings of the uterus and the uterine cavity in women with postpartum
endometritis, after caesarean section (CS) and after manual evacuation of
the placenta, and to compare these women with those in a normal
puerperium; Concluded that the ultrasonic findings in women with
44
postpartum endometritis, after CS and after manual evacuation of the

placenta, do not differ substantially from those during an uncomplicated
puerperium and A delayed uterine involution process might explain the
slight morphological differences observed.
Subinvolution Of The Placental Site
Subinvolution of the placental site may be suspected when

hypoechoic tortuous vessels are seen along the inner third of the
myometrium. Pulsed wave Doppler sonography shows increased peak
systolic velocity (PSV) (>0.83 m/s; normal 0.22 m/s three days postpartum,
falling to 0.10 m/s after six weeks) with a low-resistance waveform along
the inner third of the myometrium. The increased areas of vascularity
correlate with the placental implantation site documented by pre-delivery
sonography. However, these findings cannot always be differentiated from
congenital or acquired arteriovenous malformations, and retained products
of conception may mimic these findings when echogenic tissue is present
within the endometrial cavity (Mulic-Lutvica, 2012).
Vascular Malformations (AVMS)
Arteriovenous malformation (AVM) and pseudoaneurysm have

characteristic features on ultrasound and although the current gold standard
diagnostic test is pelvic angiography, the use of Doppler ultrasound can
successfully identify these vascular lesions (Hashim and Nawawi, 2013).
Ultrasound findings of an AVM include multiple hypoechoic or

anechoic serpentine spaces highly vascular localized area within the
myometrium, with turbulent flow on color Doppler and high-velocity and
low-resistance flow on spectral analysis (Polat et al., 2002). A PSV >0.83
45
m/s in vascular malformations has been associated with a high risk of

hemorrhage, while PSV <0.83 m/s has been associated with at lower risk
and PSV <0.39 m/s has been associated with a low risk (Timmerman et
al., 2003).
Ultrasound findings of a uterine artery pseudoaneurysm may

include a hypoechoic intrauterine lesion, vascularity on color Doppler, and
bidirectional systolic and diastolic flow with aliasing on spectral Doppler
(Nanjundan et al., 2011).
Figure (13): Colour Doppler reveals localised, highly vascular AVMs within
the myometrium identified on transvaginal scan (sagittal plane). Journal of
the British Medical Ultrasound Society
Postpartum Endometritis
Although postpartum endometritis is one of the most common

clinical conditions that develops in 2-5% of women following delivery
(Dewhurst, 1966), US findings of the uterus and uterine cavity have not
been studied extensively. Previously, the presence of gas in the uterine
46
cavity has been believed to be the typical US finding of endometritis.

Uterine involution may be delayed in cases of endometritis, particularly if
endomyometritis is present. Clinical and US findings of RPT and
endometritis have also been considered to overlap and results of previously
published studies on endometritis are contradictory. Some overlap between
clinical findings of postpartum endometritis and SPH should exist since
they are not mutually exclusive conditions (Mulic-Lutvica, 2007).
Figure (14): 34-year-old woman with retained products of conception after

vaginal delivery and failed medical therapy who presented with fever and
cramping. A, Sagittal (A) and coronal (B) images from transvaginal
ultrasound show echogenic retained products of conception and foci of
higher echogenicity representing gas (arrows) in uterus. Endometritis was
suggested on imaging and confirmed clinically. Patient was treated with
dilation and evacuation.
47
PATIENTS AND METHODS
Research Design
This was cross sectional prospective comparative study that was

conducted at Obstetric and gynecological department at Faculty of
Medicine, Zagazig University in the period from October 2018 to October
2019.
Before the start of the study, permission was obtained from the
Institutional Review Board (IRB) and Ethical Committee in the faculty of
medicine, Zagazig University. Also Informed consent from patients
included in the study was obtained.
Patients
This study was conducted on 162 post-partum women who were

deliver at the Obstetric and gynecological department at Faculty of
Medicine, Zagazig University hospitals, they was divided into two groups:
- Group I (Normal vaginal delivery group): included 81 women who

were deliver by normal vaginal delivery.
- Group II (cesarean section group): included 81 women were deliver

by cesarean section.
48
All the women participating in this study were according to the

following criteria:
 Inclusion Criteria:
All postpartum women in Obstetric and gynecological department

at Faculty of Medicine, Zagazig University hospitals
 Exclusion Criteria:
- Any post-partum woman with chronic diseases e.g. hypertension and
diabetes mellitus.
- Women with history of pre-eclampsia or eclampsia.
- Women with congenital or acquired uterine lesions.
- Women with intra-partum surgical interference e.g. uterine artery

ligation
Methods:
After informed written consent were obtained from all patients

included in the study they were subjected to the followings:
I. Full Medical History:
Full medical history was taking from all participants including:
- Personal history: Name, Age, occupation, address, special habits,

parity, No. of kids … etc.
- Past history: of parity, complications of pregnancy or any medical

disease can cause bleeding tendency.
49
- Menstrual and Obstetric and history:
 Age of menarche and Last menstrual period
 Gravidity, parity, and pregnancy outcomes.
 Any complication during pregnancy, labor or puerperium.
II. Full general examination:
Including cardiological, chest, abdominal and monitoring vital data

(heart rate, systolic and diastolic blood pressure).
III. Routine preoperative investigations:
The following laboratory investigations for all participants in the

study:
- Complete blood picture (CBC).
Measured by an automatic cell counter (Mindray PC 2800

Hematology Analyzer).
- Kidney Function tests (Bl. Urea and S. Cr)
- Liver function test (S. AST, S. ALT, S. albumin, Total bilirubin).
Examined by Semi-Automated Clinical Chemistry Analyzer

(MICROLAB 300) to exclude patients with abnormal kidney or liver
functions or hidden general chronic medical diseases.
50
IV. Day of starting breast feeding:
V. Sonographic Evaluation:
Ultra-sonographic examination were done to all participants at post-

partum day 7 and 40 by transabdominal probe with genital compression
and the measurements were done between uterine contractions. The uterus
dimensions were assessed in longitudinal section and the anteroposterior
(AP) diameters of the uterus and uterine cavity was measured
perpendicular to the endometrium thickness. The shape and position of the
uterus were recorded. Also, the presence or absence of echo-free fluid and
echogenicity within the uterine cavity and presence of abnormal contents,
echogenic mass or gas in the uterine cavity.
51
STATISTICAL ANALYSIS
The collected data was revised, coded, tabulated and introduced to
a PC using Statistical package for Social Science (SPSS version 20.0 for
windows; SPSS Inc, Chicago, IL, 2001). Data was presented and suitable
analysis was done according to the type of data obtained for each
parameter.
I. Descriptive Statistics:
1. Mean, Standard deviation (± SD) and range for parametric numerical

data, while Median and Interquartile range (IQR) for non-parametric
numerical data.
2. Frequency and percentage of non-numerical data.
II. Analytical Statistics:
1. Student T Test: was used to assess the statistical significance of the

difference between two study group means.
2. Mann Whitney Test (U test): was used to assess the statistical
significance of the difference of a non-parametric variable between two
study groups.
3. Chi-Square test (X2): was used to examine the relationship between
two qualitative variables
4. Paired t-test: was used to assess the statistical significance of the
difference between two means measured twice for the same study
group.
III. P- value: level of significance
- P>0.05: Non significant (NS).

- P< 0.05: Significant (S).
- P<0.01: Highly significant (HS).
52
RESULTS
RESULTS
Table (1): Socio-demographic data of the two studied groups:
Group I (NVD) Group II (CS)

Variable t p
(n=81) (n=81)
Age : (year)
- Mean ± SD 2.09 0.04*
26.38 ± 4.63 28.1 ± 5.78
- Range 19 - 36 20 - 41
Variable No % No % χ2 P
Parity:
- Primi 16 19.8 12 14.8
- Secundi 7.8 0.02*
27 33.3 14 17.3
- Multi 38 46.9 55 67.9
SD: Stander deviation; t: Independent t test; χ2: Chi square test, *: Significant (P<0.05)
This table shows:
There were statistical significance increase in mean age and

frequency of multipara among CS group compared to NVD group.
Figure (1): Age distribution of the two studied groups.
53
RESULTS
Figure (2): Parity distribution of the two studied groups.
54
RESULTS
Table (2): Gestational age at delivery among the two studied groups:

Variable (n=81) (n=81) χ2 P
No % No %
GA:
- 38+ 24 29.6 55 67.9
- 39+ 41 50.6 14 17.3 25.99 <0.001
- 40+ 16 19.8 12 14.8 **
χ2: Chi square test **: Highly significant (P<0.01)
This table shows:
There were statistical significance increase in frequency of GA 38+

among Group II (CS) compared to Group I (NVD).
Figure (3): Gestational age at delivery among the two studied groups.
55
RESULTS
Table (3): Breast feeding and day among the two studied groups:

Variable (n=81) (n=81) χ2 P
No % No %
Breast feeding:
- No 18 22.2 18 22.2 0 1
- Yes 63 77.8 63 77.8 NS
Day:
- Day 7 45 55.6 55 67.9 2.61 0.10
- Day 40 36 44.4 26 32.1 NS
χ2: Chi square test NS: Non significant (P<0.05)
This table shows:
There were no statistical significance differences between the two

groups in frequency of breast feeding or day.
Figure (4): Frequency of breast feeding among the two studied groups.
56
RESULTS
Figure (5): Day among the two studied groups.
57
RESULTS
Table (4): Width at 7th day and 40th day among the two studied
groups:

Variable t p
(n=81) (n=81)
Width 7th day: (cm)
- Mean ± SD 7.64 ± 0.70 7.42 ± 0.52 2.21 0.03*
- Range 6.12 – 8.9 6.56 – 8.4
Width 40th day: (cm)
- Mean ± SD 4.93 ± 0.39 4.94 ± 0.51 0.15 0.89
- Range 4.3 – 5.8 3.73 - 6 NS
Paired t 30.25 29.71
P <0.001** <0.001**
% of change -34.82% -33.03%
SD: Stander deviation; t: independent t test; Paired t: Paired t test; NS: Non significant (P>0.05);
*: Significant (P<0.05); **: Highly significant (P<0.01)
This table shows:
There were statistical significance difference between Group I

(NVD) and Group II (CS) in width at 7th day but no difference was found
between them in 40th day. Also there were statistical significance decrease
in width from 7th day to 40th day in both groups by 34.82% & 33.03%
respectively.
Figure (6): Width among the two studied groups at 7th and 40th day.
58
RESULTS
Table (5): Length at 7th day and 40th day among the two studied
groups:

Variable Test p
(n=81) (n=81)
Length 7th day: (cm)
- Mean ± SD 13.74 ± 1.17 11.81 ± 1.11 10.75 <0.001
- Range 11.05 – 15.87 9.85 – 13.8 **
Length 40th day: (cm)
- Mean ± SD 6.70 ± 0.76 6.64 ± 0.86 0.44 0.66
- Range 5.1 – 7.85 3.73 – 7.91 NS
Paired t 42.37 35.61
P <0.001** <0.001**
% of change -50.77% -43.32%
SD: Stander deviation t: independent t test Paired t: Paired t test NS: Non significant
(P>0.05) **: Highly significant (P<0.01)
This table shows:

(NVD) and Group II (CS) in length at 7th day but no difference was found
in length from 7th day to 40th day in both groups by 50.77% & 43.32%
respectively.
Figure (7): Length among the two studied groups at 7th and 40th day.
59
RESULTS
Table (6): AP diameter at 7th day and 40th day among the two studied
groups:

Variable Test p
(n=81) (n=81)
AP diameter 7th day: (cm)
- Mean ± SD 6.34 ± 0.64 6.14 ± 0.60 2.09 0.04*
- Range 5.23 – 7.5 4.88 – 7.2
AP diameter 40th day: (cm)
- Mean ± SD 3.28 ± 0.43 4.01 ± 0.61 8.83 <0.001**
- Range 2.57 – 4.02 2.87 – 4.81
Paired t 34.23 35.80
P <0.001** <0.001**
% of change -47.76% -34.61%
SD: Stander deviation t: independent t test Paired t: Paired t test *: Significant
(P<0.05) **: Highly significant (P<0.01)
This table shows:

(NVD) and Group II (CS) in AP diameter at 7th day and 40th. Also there
were statistical significance decrease in AP diameter from 7th day to 40th
day in both groups by 47.76% & 34.61% respectively.
Figure (8): AP diameter among the two studied groups at 7th and 40th day.
60
RESULTS
Table (7): Cavity at 7th day and 40th day among the two studied
groups:

Variable Test p
(n=81) (n=81)
Cavity 7th day: (cm)
t
- Mean ± SD 1.12 ± 0.34 1.3 ± 0.38
3.10 <0.002**
- Range 0.6 - 2 0.6 - 2
Cavity 40th day: (cm)
- Mean ± SD 0.41 ± 0.74 0.34 ± 0.65 MW 0.24
- Median 0.14 0.1 1.18 NS
- Range 0.04 – 2.6 0.04 – 2.6
Paired W 7.20 11.66

P <0.001** <0.001**
% of change -53.90% -73.04%
SD: Stander deviation t: independent t test MW: Mann Whitney test Paired W: Paired
Wilcoxon test NS: Non significant (P>0.05) **: Highly significant (P<0.01)
This table shows

(NVD) and Group II (CS) in cavity at 7th day but no difference was found
in cavity from 7th day to 40th day in both groups by 53.9% & 73.04%
respectively.
61
RESULTS
Figure (9): Cavity among the two studied groups at 7th and 40th day.
62
RESULTS
Table (8): Relation between breast feeding and different measurement

among NVD group:
Variable No BF BF
(n=18) (n=63) t p
- Mean ± SD 7.94 ± 0.75 7.55 ± 0.66 0.06

Width 7th day (cm) 1.99
- Range 6.85 – 8.9 6.12 – 8.74 NS
- Mean ± SD 4.98 ± 0.35 4.92 ± 0.41 0.55

- Range 4.3 – 5.3 4.34 – 5.8 NS
Paired t 19.73 24.96
P <0.001** <0.001**
% of change -53.67% -49.94%
- Mean ± SD 14.06 ± 1.39 13.65 ± 1.09 0.19
Length 7th day (cm) 1.33
- Range 11.05 – 15.87 11.5 – 15.87 NS
- Mean ± SD 6.46 ± 0.51 6.77 ± 0.81 0.13

- Range 5.28 – 7.1 5.1 – 7.85 NS
Paired t 24.75 35.99
P <0.001** <0.001**
% of change -36.89% -34.23%
AP diameter 7th day - Mean ± SD 6.46 ± 0.63 6.31 ± 0.64 0.37
0.91
(cm) - Range 5.65 – 7.44 5.23 – 7.5 NS
AP diameter 40th day - Mean ± SD 3.50 ± 0.35 3.34 ± 0.43

2.61 0.01*
(cm) - Range 2.6 – 3.75 2.57 – 4.02
Paired t 15.92 31.28
P <0.001** <0.001**
% of change -52.03% -46.54%
- Mean ± SD 1.09 ± 0.22 1.14 ± 0.37 0.59
Cavity 7th day (cm) 0.54
- Range 0.8 – 1.5 0.6 - 2 NS
- Mean ± SD 0.13 ± 0.05 0.49 ± 0.82

MW 0.99
Cavity 40th day (cm) - Median 0.1 0.1
0.01 NS
- Range 0.4 – 0.24 0.4 – 2.6
Paired W 3.73 4.17

P <0.001** <0.001**
% of change -86.57% -44.57%
SD: Standard deviation t: independent t test MW: Mann Whitney test Paired t: Paired
t test Paired W: Paired Wilcoxon test NS: Non significant (P>0.05) **: Highly significant
(P<0.01)
63
RESULTS
This table shows
There were no statistical significance difference between breast

feeding and non-breast feeding cases in NVD group in width, length, AP
diameter or cavity at 7th day or in width, length or cavity at 40th day but
there were statistical significance difference was found between them in
AP diameter at 40th day. Also there were statistical significance decrease
in all measures from 7th day to 40th day in both breast feeding and non-
breast feedings.
64
RESULTS
Figure (10): Different measurement among the NVD group according to

breast feeding at 7th and 40th day.
65
RESULTS
Table (9): Relation between breast feeding and different measurement

among CS group:
No BF BF
Variable t P
(n=18) (n=63)
- Mean ± SD 7.06 ± 0.38 7.52 ± 0.51

Width 7th day (cm) 3.62 0.001**
- Range 6.65 – 7.85 6.56 – 8.4
- Mean ± SD 4.87 ± 0.43 4.96 ± 0.53 0.48

- Range 4.21 – 5.41 3.73 - 6 NS
Paired t 16.38 26.07
P <0.001** <0.001**
% of change -30.84% -33.65%
- Mean ± SD 11.34 ± 0.97 11.95 ± 1.13
Length 7th day (cm) 2.05 0.04*
- Range 10.4 – 12.67 9.85 – 13.8
- Mean ± SD 6.32 ± 0.88 6.74 ± 0.83 0.07

- Range 5.1 – 7.85 3.73 – 7.91 NS
Paired t 23.94 29.41
P <0.001** <0.001**
% of change -44.22% -43.06%
0.86
(cm) - Range 5.15 - 7 4.88 – 7.2 NS

2.74
(cm) - Range 2.87 – 4.73 2.92 – 4.81 **
Paired t 18.49 31.55
P <0.001** <0.001**
% of change -38.94% -33.37%
- Mean ± SD 1.25 ± 0.41 1.31 ± 0.37 0.54
Cavity 7th day (cm) 0.61
- Range 0.7 – 1.8 0.6 - 2 NS
- Mean ± SD 0.10 ± 0.07 0.42 ± 0.73

MW
Cavity 40th day (cm) - Median 0.08 0.1
1.69 0.09 NS
- Range 0.04 – 0.24 0.04 – 2.6
Paired W 3.73 5.64

P <0.001** <0.001**
% of change -91.40% -67.80%
SD: Standard deviation t: independent t test MW: Mann Whitney test Paired t:Paired
t test Paired W: Paired Wilcoxon test NS: Non significant (P>0.05) **: Highly significant
(P<0.01)
66
RESULTS
This table shows
There were no statistical significance difference between breast

feeding and non-breast feeding cases in CS group in AP diameter or cavity
at 7th day or in width, length or cavity at 40th day but there were statistical
significance difference was found between them in width at 7th day, length
at 7th day and AP diameter at 40th day. Also there were statistical
significance decrease in all measures from 7th day to 40th day in both
breast feeding and non-breast feedings.
67
RESULTS
Figure (11): Different measurement among the CS group according to

breast feeding at 7th and 40th day.
68
RESULTS
69
DISCUSSION
DISCUSSION
Since the introduction of ultrasonography into the obstetric
practice, performing non-invasive investigations of the uterus was made
possible. Several authors have examined the uterus by ultrasonography
after vaginal births (Kristoschek et al, 2017). Sokol et al performed
ultrasound exams 48 hours after vaginal birth (Sokol et al, 2004). Edwards
and Ellwood evaluated 40 patients on postpartum days 7, 14 and 21
(Edwards and Ellwood, 2000). Al-Bdour et al evaluated women on
postpartum days 1, 7, 14, 28 and 56 (Al-Bdour et al, 2004). Defoort et al
performed ultrasound examinations in the first 24 hours after vaginal birth,
and found a significant correlation between parity and uterine involution
(Defoort et al., 1978). Many authors evaluated uterus involution after birth
using a three-dimensional (3D) ultrasound (Kristoschek et al, 2017).
Belachew et al studied using the transabdominal ultrasound on days 1, 7
and 14, and the transvaginal ultrasound on days 28 and 56 postpartum in
63 women after spontaneous delivery. The median uterine volume
decreased from 756 cm3 on day 1 postpartum to 440 cm3 on day 7. The
mean uterine volume was decreased by 41.8% (Belachew et al., 2012).
Wataganara et al found a high correlation between two-dimensional (2D)
and 3D ultrasound estimations of the uterine volume (Wataganara et al,
2015).
The uterus naturally regresses during the peurperium, with the most
rapid involution occurring during the first week (Gal zener et al., 1993).
The uterus regains its usual non pregnant size within six weeks, going from
1000 gr. immediately postpartum to 100 gr. In pregnancy the muscle fibers
eventually become ten times as long &five times as broad, those in resting
70
DISCUSSION
organ .The stimulus is partly mechanical &partly hormonal. Regeneration

of the endometrium is complete by third week postpartum but regeneration
of placental site not complete until 5-6 weeks (Walter and Srael, 1987).
To understand the normal involution process of the uterus after delivery
&the sonographic variations in tissue texture, anatomical clarity
&incidental findings will critically assist in the identification of pathology
(Demecko et al., 1989).
The aim of this study was to describe the changes in the uterine
dimensions using ultrasound in the early puerperium following cesarean
section or vaginal birth among women delivering term singleton infants
who experienced an uncomplicated postpartum period. A secondary
objective was to assess the influence of parity, mode of delivery and
breastfeeding on uterine involution according to the time at which it was
assessed.
The study included 81 patients delivered vaginally (group 1) and

81 patients delivered by CS (group 2). The mean maternal age of the
patients increased significantly among those delivered by CS when
compared to those delivered vaginally (28.1 ± 5.78 versus 26.38 ± 4.63
respectively). This was similar to Negishi et al who found that the mean
maternal age of the patients increased significantly among those delivered
by CS when compared to those delivered vaginally 1month (30.77±5.61
versus 29.16±4.97 respectively) and 3 months (30.94±5.28 versus
29.19±4.92 respectively) after delivery (Negishi et al., 1999).
In our study delivery by CS increased significantly among

multipara when compared to VD. This was in contrast to a similar study by
Negishi et al who found that there was no significant difference in parity
71
DISCUSSION
between the vaginal delivery group and the cesarean section group
(Negishi et al., 1999).
In this study 29.6% of group 1 (NVD) patients delivered at 38

weeks gestational age and 67.9% of group 2 (CS) patients delivered at 38
weeks gestational and the difference between both groups was highly
statistically significant. The week of pregnancy at delivery was earlier in
the CS group than in the VD group. This was similar to Negishi et al who
also found that the week of pregnancy at delivery was earlier in the CS
group than in the VD group 1 month (38.00±2.48 versus 39.30±1.38
respectively) and 3 months (38.10±2.02versus 39.24±1.40 respectively)
after delivery (Negishi et al., 1999).
There was no statistically significance difference between the two

groups in frequency of breast feeding or day of start of feeding 7 and 40
days after delivery. In a study by Negishi et al there was no significant
difference in the rate of breast-feeding per day in the VD group and the CS
group at one month (58% and 53%, respectively), however the breast-
feeding rate in the VD group was higher than the CS group at 3 months
after delivery (53% and 39%, respectively, p<0.05) (Negishi et al., 1999).
Al- Bassam found that the mean percentage drop of uterine size in
vaginal delivery is faster than caesarean delivery at 7 days (39.9% vs.
27.9%) &14 days postpartum.(62.7 % vs. 55.2%) (p<0.05) (Al- Bassam,
2009). This can be explained by the fact that vaginal delivery is normal
process causing no iatrogenic injury to the myomatrium while in caesarean
section the uterine incision undergoes healing by regeneration of muscle
fibre with little or no response (Lavery et al., 1985). J.Patrick (1989)
found there was no difference between method of delivery and uterine
involution. He use the mean area of uterus in flat plane (cm.) while in our
72
DISCUSSION
study the uterine volume is used &probably this is more accurate way for
uterine measurement as it involves the entire uterine dimension (Patrick
et al., 1989).
There was statistically significance difference between Group I

between them in 40th day. Also there was statistical significance decrease
respectively. In a similar study by Kristoschek et al the uterus transverse
diameter was 12.5 cm on D1. The average diameter was 11.8 cm on D2,
which represented a decrease of 5.1%, and the average was 10.1 cm on D7,
which represented a decrease of 20.0% (Kristoschek et al, 2017).

respectively. In a similar study by Kristoschek et al the mean uterine
longitudinal diameter was 18.3 cm on D1. It decreased by 3.9% on D2 to
an average of 17.6 cm, and it decreased by 20.9% on D7 to an average of
14.5 cm. c) (Kristoschek et al, 2017).

was statistically significance decrease in AP diameter from 7th day to 40th
day in both groups by 47.76% & 34.61% respectively. In a similar study
by Kristoschek et al the uterine anteroposterior diameter decreased by
5.5% from D1 to D2, corresponding to an average change from 8.0 to 7.6
cm. Reductions in size were maintained until D7, when the average was
73
DISCUSSION
7.1 cm, corresponding to a reduction of 11.8%. d) (Kristoschek et al,

2017).

(NVD) and Group II (CS) in length of the cavity at 7th day but no
difference was found between them in 40th day. Also there was statistically
significance decrease in cavity from 7th day to 40th day in both groups by
53.9% & 73.04% respectively. In a similar study by Kristoschek et al the
variations in the dimensions of the thickness and length of the uterine
cavity during the study period were also verified. a) In the first week
postpartum, the uterine cavity thickness decreased by 23%; the average
thickness decreased from 0.7 cm on D1 to 0.57 cm on D7. b) The uterine
cavity length decreased by 27.2% during the same period; the average
length decreased from 13.4 cm on D1 to 9.7 cm on D7 (Kristoschek et al,
2017).
Koskas et al postulated that discrepancies between uterine

measurements can occur due to the differences among the surgical
techniques and the doses of oxytocin given following a cesarean section,
which can be different than those given to patients following a vaginal birth
(Koskas et al., 2008). Bae et al evaluated uterine involution 2 and 6 weeks
postpartum. They showed differences in relation to delivery mode and
gestational age at delivery (Bae et al., 2012).
According to human physiology, the oxytocic hormone or oxytocin

which is octapeptide secreted by posterior pituitary is so named because of
its ability to cause uterine muscle & myoepithial breast duct cell
contraction and these stimulate both labor and lactation, it released by
complex neuroendocrine mechanisms, its action to enhance rhythmic
uterine contraction during labor probably due to release of calcium ions in
74
DISCUSSION
the myometrium, which bring about the smooth muscle contraction.

Oxytocin released during milk letdown causes increased uterine
contraction, hastens uterine involution, and thus decreases postpartum
blood loss (American Academy of Paediatrics, 2005).
There was no statistically significance difference between breast

there was statistically significance difference was found between them in
AP diameter at 40th day. Also there was statistically significance decrease
breast feedings.
There was no statistical significance difference between breast

at 7th day or in width, length or cavity at 40th day but there was statistical
at 7th day and AP diameter at 40th day. Also there was statistical
In a study by Kristoschek et al significant direct correlation was

found between breastfeeding and the uterine volume (p=0.04), regardless
of time, although the number of puerperal women who reported exclusive
breastfeeding (80) was much higher than the number of women who
reported other breastfeeding practices (11), which prevented a meaningful
statistical analysis (Kristoschek et al, 2017). Rodeck and Newton
(Rodeck and Newton, 1976), Defoort et al (Defoort et al., 1978), Buisson
et al (Buisson et al., 1993), Wachsberg et al (Wachsberg et al., 1994),
Mulic-Lutvica et al (Mulic-Lutvica et al., 2001), Sokol et al (Sokol et al.,
75
DISCUSSION
2004) and Wataganara et al (Wataganara et al, 2015) considered the

uterine volume to be independent of breastfeeding.
In a study by Negishi et al the association between breast-feeding

and recovery of the uterus was also examined. There was no significant
difference in uterine size between breast- or bottle-feeding mothers at one
month after delivery in our investigation. However, a difference in uterine
size related to feeding methods was found at 3 months after delivery. The
fact that the mean breast-feeding rate in the VD group (52.8%) at three
months was higher than in the CS group (39.4%) may partially explain the
difference in uterine size between the two groups at 3 months after
delivery. Their finding suggests that the earlier ambulation in the VD group
than the CS group may not be responsible for the difference in uterine size,
but some other factors may affect the different size of the uterus between
the VD group and the CS group at one and 3 months postpartum (Negishi
et al., 1999).
Van Rees et al reported that the decrease in uterine size was related
to a diminution in uterine length and that they found no difference between
breast- and bottle-feeding mothers in examinations between 1 and 40 days
postpartum. Their findings are the same as ours one month after delivery
(Van Rees et al., 1981). Defoort et al (Defoort et al., 1978) and
Wachsberg et al (Wachsberg et al., 1994) also reported the absence of
any relation between uterine involution and breast-feeding. However, there
was a clear difference between puerperants who breast-fed immediately
after birth and those who resorted to artificial methods: uterine volume
diminished more rapidly in the former, especially between days 1–4 (Galli
et al., 1993).
76
SUMMARY
SUMMARY
During the postpartum period, the uterus, which weighs over 1 kg
immediately after parturition, undergoes a physiological involution and
returns to the non-pregnant condition. The process of involution, which is
one of the main characteristics of the postpartum period, may be affected
in pathological conditions such as uterine infection and hemorrhage. Both
are main causes of maternal death worldwide; therefore, a correct diagnosis
is of paramount importance.
The uterine involution has been previously evaluated with respect

to the palpation of the uterine height, which can be difficult in obese
women or in those with uterine myoma. The uterus was one of the first
organs to be examined by ultrasonography when ultrasound was
introduced into the clinical practice by Donald and his collaborators. The
high-resolution ultrasound equipment that is currently available increases
the role of ultrasonography in assessing the normal and abnormal puerperal
dynamics. Ultrasonography is a non-invasive, low cost technique that is
well accepted by patients.
There is no consensus in the literature regarding the influence of

some factors, such as parity, breastfeeding and birth weight on uterine
involution. It is important to know the normal ultrasonographic involution
of the uterus during the postpartum period to improve our ability to
distinguish the pathological from the normal puerperium and thereby avoid
unnecessary invasive procedures. Furthermore, the knowledge obtained
from ultrasonographic examinations can help us better understand the
physiology of the postpartum period. The postpartum period has been
arbitrarily divided into the immediate puerperium, or the first 24 hours after
77
SUMMARY
parturition; the early puerperium, which extends until the first week
postpartum; and the remote puerperium, which includes the period of time
required for involution of the genital organs and return of menses, usually
about 6 weeks.
The aim of this study was to describe the changes in the uterine
dimensions using ultrasound in the early puerperium following cesarean
section or vaginal birth among women delivering term singleton infants
who experienced an uncomplicated postpartum period. A secondary
objective was to assess the influence of parity, mode of delivery,
breastfeeding and birthweight on uterine involution according to the time
at which it was assessed.
This study was conducted in Obstetrics and Gynecology

Department Faculty of medicine in Zagazig University. We included all
postpartum women in Obs. & Gyn Department at Faculty of Medicine in
Zagazig University.
Exclusion criteria were: Women with history of preeclampsia or

eclampsia, diabetic women, women with congenital or acquired uterine
pathology, women with intra partum surgical interference e g, uterine
artery ligation.
In day 7 and day 40 postpartum uterine measures were obtained in

between uterine contractions by ultrasound. The uterus was assessed in
longitudinal section & the maximum anteroposterior diameter of the uterus
and uterine cavity was measured perpendicular to the endometrium. The
shape and the position of the uterus were recorded. The presence of fluid,
abnormal contents, echogenic mass or gas in the uterine cavity was also
recorded.
78
SUMMARY
The study included 81 patients delivered vaginally (group 1) and

81 patients delivered by CS (group 2). There was statistically significance
increase in mean age and frequency of multipara among CS group
compared to NVD group.
There was statistically significance increase in frequency of GA

38+ among Group II (CS) compared to Group I (NVD). There was no
statistically significance difference between the two groups in frequency
of breast feeding or day.

respectively.

respectively.

was statistically significance decrease in AP diameter from 7th day to 40th
day in both groups by 47.76% & 34.61% respectively.

(NVD) and Group II (CS) in cavity at 7th day but no difference was found
between them in 40th day. Also there was statistically significance
79
SUMMARY
decrease in cavity from 7th day to 40th day in both groups by 53.9% &
73.04% respectively.
There was no statistically significance difference between breast

there was statistically significance difference was found between them in
AP diameter at 40th day. Also there was statistically significance decrease
breast feedings.
There was no statistical significance difference between breast

at 7th day or in width, length or cavity at 40th day but there was statistical
at 7th day and AP diameter at 40th day. Also there was statistical
80
CONCLUSION AND RECOMMENDATION
CONCLUSION AND RECOMMENDATIONS
- The uterus naturally regresses during the puerperium, with the most
rapid involution occurring during the first week.
- Ultrasound is a valuable adjunct to the obstetrician in cases of potential

puerperal morbidity by knowing the normal involution process of the
uterus after delivery as the sonographic variations in tissue texture,
anatomical clarity and incidental findings will critically assist in the
identification of pathology.
- Preventive ultrasonic examination in the puerperium before leaving the

hospital can forestall postpartum complication.
- Increased maternal age and parity are associated with increased

frequency of CS.
- Delivery by CS is earlier than vaginal delivery as regard gestational

age.
- Frequency of breast feeding is equal in patients delivered by CS or

delivered vaginally.
- There was statistical significance difference between Group I (NVD)

and Group II (CS) in uterine length, uterine width, uterine A-P diameter
and length of the uterine cavity at 7th day but no difference was found
between them in 40th day.
- There was statistical significance decrease in uterine length, uterine

width, uterine A-P diameter and length of the uterine cavity from 7th
day to 40th day in both groups.
81
CONCLUSION AND RECOMMENDATION
- In both groups, there was statistical significance decrease in all

measures of the uterus from 7th day to 40th day in both breast feeding
and non-breast feedings.
- Further studies on large sample are required to prove our results.
82
REFERENCES
REFERENCES
Al- Bassam AN. Uterine involution after term childbirth. J Fac Med
Baghdad. Vol. 8 51, No 1, 2009.
Al-Bdour AN, Akasheh HF, Al-Husban NA. (2004): Ultrasonography of

the uterus after normal vaginal delivery. Saudi Med J, 25; 1:41-4.
Al-Bdour ANA, Akasheh HF, Al-Husban NA. Ultrasonography of the

uterus after normal vaginal delivery. Saudi Med J 2004; 25(01):41–
44.
Alexander J, Thomas PW ans Sanghera J. (2002): Treatments for

secondary postpartum haemorrhage. Cochrane Database Syst Rev,
1:CD002867.
American Academy of Paediatrics: Policy statement: breastfeeding &the

use of Human Milk.Pediatrics 2005; 115(2):496-506.
Antony KM, Racusin DA, Kjersti Aagaard K, et al. (2016): Ch. 3:

Maternal physiology. In Gabbe SG, Niebyl JR, Simpson JL,
editors: Obstetrics: Normal and Problem Pregnancies E-Book.
Elsevier Health Sciences. p: 38 – 63.
Bae HS, Ahn KH, Oh MJ, Kim HJ, Hong SC. Postpartum uterine
involution: sonographic changes in the endometrium between 2and
6 weeks postpartum related to delivery mode and gestational age at
delivery. Ultrasound Obstet Gynecol 2012;39(06):727–728
Baskett TF. (2000): A flux of the reds: evolution of active management of

the third stage of labour. J R Soc Med, 93; 9:489-93.
83
REFERENCES
Belachew J, Axelsson O, Mulic-Lutvica A, Eurenius K. Longitudinal

study of the uterine body and cavity with three-dimensional
ultrasonography in the puerperium. Acta Obstet Gynecol Scand
2012;91(10):1184–1190.
Berens P, Lockwood CJ and Eckler K. (2017): Overview of the

postpartum period: Physiology, complications, and maternal care.
Available at https://www.uptodate.com/contents/overview-of-the-
postpartum-period-physiology-complications-and-maternal-care.
Buisson P, Tomikowski J, Santarelli J, Kapitaniak B. Clinical and

ultrasonographic study of uterine involution in postpartum
physiology. Rev Fr Gynecol Obstet 1993;88(01):12–18
Carlan SJ, Scott WT, Pollack R, et al. (1997): Appearance of the uterus
by ultrasound immediately after placental delivery with pathologic
correlation. J Clin Ultrasound, 25; 6:301–308.
Carlan SJ, Scott WT, Pollack R, et al. (1997): Appearance of the uterus
by ultrasound immediately after placental delivery with pathologic
correlation. J Clin Ultrasound. 1997 Jul-Aug;25(6):301-8.
Chibueze EC, Parsons AJ, Ota E, et al. (2015): Prophylactic antibiotics

for manual removal of retained placenta during vaginal birth: a
systematic review of observational studies and meta-analysis.
BMC Pregnancy Childbirth, 15: 313.
Cunningham FG, Kenneth J. Leveno, Steven L. Bloom, et al. (2014):

Ch. 36: The Puerperium. In Williams OBSTETRICS. 24th edition.
24e. Mcgraw-hill. P: 662 – 82.
84
REFERENCES
De Winter J, De Raedemaecker H, J Muys J, et al. (2017): The value of

postpartum ultrasound for the diagnosis of retained products of
conception: A systematic review. Facts Views Vis Obgyn, 9; 4:
207–216.
Deans R and Dietz HP. (2006): Ultrasound of the post-partum uterus.

Aust N Z J Obstet Gynaecol, 46; 4:345-9.
Defoort P, Benijts G, Thiery M, Martens G. Ultrasound assessment of

puerperal uterine involution. Eur J Obstet Gynecol Reprod Biol
1978;8(02):95–97.
Demecko-D, Slezak-P, Hubkova-B, Zentraibl-gynakol, 1989, 11(4):211-

6.
Dewhurst CJ. (1966): Secondary post-partum haemorrhage.J Obstet

Gynaecol Br Commonw, 73; 1:53-8.
Donald I, Macvicar J and Brown TG. (1958): Investigation of abdominal

masses by pulsed ultrasound. Lancet, 1; 7032:1188-95.
Dossou M, Debost-Legrand A, Déchelotte P, et al. (2015): Severe

secondary postpartum hemorrhage: a historical cohort. Birth, 42;
2:149-55.
Drife J. (2005): Why mothers die. J R Coll Physicians Edinb, 35:332–336.
Dubreuil G and Loubat E. (1926): Aneurisme circoid de l'uteerus. Ann

Anat Pathol, 3: 697–718.
Edhi MM, Aslam HM, Naqvi Z, et al. (2013): Postpartum hemorrhage:

causes and management. BMC Res Notes, 6:236.
85
REFERENCES
Edwards A and Ellwood DA. (2000): Ultrasonographic evaluation of the

postpartum uterus. Ultrasound Obstet Gynecol, 16; 7:640-3.
Edwards A, Ellwood DA. Ultrasonographic evaluation of the postpartum

uterus. Ultrasound Obstet Gynecol 2000;16(07): 640–643.
Fletcher S, Grotegut CA, James AH. (2012): Lochia patterns among

normal women: a systematic review. J Womens Health (Larchmt),
21; 12:1290 – 4.
Fukuda M, Fukuda K, Shimizu T, et al. (2016): Ultrasound Assessment

of Lower Uterine Segment Thickness During Pregnancy, Labour,
and the Postpartum Period. J Obstet Gynaecol Can, 38; 2:134-40.
Gal zener CMA, Mac Arther C&Garcia J (1993) postnatal care: time
for a charge .Contemp Rev Obstet Gynaecol 5, 130-6.
Galli D, Groce P, Chiapparini I, Dede A (1993) Ultrasonic evaluation of

the uterus during puerperium. Valutazione ecografic dell’utero in
puerperio. Minerva Ginecol 45:473–478.
Guarino A, Di Benedetto L, Assorgi C, et al. (2015): Conservative and

timely treatment in retained products of conception: a case report
of placenta accreta retention. Int J Clin Exp Pathol. 2015; 8(10):
13625–13629.
Hashim H and Nawawi O. (2013): Uterine Arteriovenous Malformation.

Malays J Med Sci. 2013 Mar; 20(2): 76–80.
J .B. Walter. S. I.Srael, General pathology (.1987).
J.Patrick Lavery, MD, Linda A. Journal of ultra sound in medicine .Vo.8,

No.9 Sep., 1989.
86
REFERENCES
Kamaya A, Petrovitch I, Chen B, et al. (2009): Retained products of

conception: spectrum of color Doppler findings. J Ultrasound Med,
28; 8:1031-41.
Kansky C, Isaacs C, Talavera F, et al. (2016): Normal and Abnormal

Puerperium. Available at
https://emedicine.medscape.com/article/260187-overview.
Kelly SM, Belli AM and Campbell S. (2003): Arteriovenous

malformation of the uterus associated with secondary postpartum
hemorrhage. Ultrasound Obstet Gynecol 2003; 21: 602–605.
Kelly SM, Belli AM, Campbell S. (2003): Arteriovenous malformation

of the uterus associated with secondary postpartum hemorrhage.
Ultrasound Obstet Gynecol, 21; 6:602 – 5.
Konar H. (2015): Ch. 5: Physiological Changes During Pregnancy in DC

Dutta's Textbook of Obstetrics. 8th edition. JP Medical Ltd, p:52 –
64.
Koskas M, Nizard J, Salomon LJ, et al. (2008): Abdominal and pelvic

ultrasound findings within 24 hours following uneventful Cesarean
section. Ultrasound Obstet Gynecol. 2008 Sep; 32(4):520-6.
Koskas M, Nizard J, Salomon LJ, Ville Y. Abdominal and pelvic

ultrasound findings within 24 hours following uneventful Cesarean
section. Ultrasound Obstet Gynecol 2008;32(04):520–526.
Kristoschek JH, Moreira de Sá RA, Campos da Silva F, Vellarde GC.

Ultrasonographic Evaluation of Uterine Involution in the Early
Puerperium. Rev Bras Ginecol Obstet 2017;39:149–154.
87
REFERENCES
Kristoschek JH, Moreira de Sá RA, Silva FCD, et al. (2017):

Ultrasonographic Evaluation of Uterine Involution in the Early
Puerperium. Rev Bras Ginecol Obstet. 2017 Apr;39(4):149-154.
Lavery JP, Howell RS,Shaw L: ultrasonic demonstration of phlegmon

following caesarean section JCU.13:134, 1985.
Marchant S, Alexander J, Thomas P, et al. (2006): Risk factors for

hospital admission related to excessive and/or prolonged
postpartum vaginal blood loss after the first 24 h following
childbirth. Paediatr Perinat Epidemiol, 20; 5:392-402.
Mori M, Bogdan A, Balassa T, et al. (2016): The decidua—the maternal

bed embracing the embryo—maintains the pregnancy. Semin
Immunopathol, 38; 6:635 – 649.
Mulic-Lutvia A. (2007): Postpartum Ultrasound. Acta Universitatis

Upsaliensis Uppsala.
Mulic-Lutvia A. (2017): Ch. 31: Postpartum Ultrasound. In Kurjak A and

Chervenak FA.: Donald School Textbook of Ultrasound in
Obstetrics & Gynaecology. 4th edition. JP Medical Ltd. P: 495 –
514.
Mulic-Lutvica A and Axelsson O. (2007): Postpartum ultrasound in

women with postpartum endometritis, after cesarean section and
after manual evacuation of the placenta. Acta Obstet Gynecol
Scand, 86; 2:210 – 7.
Mulic-Lutvica A, Axelsson O. (2006): Ultrasound finding of an

echogenic mass in women with secondary postpartum hemorrhage
88
REFERENCES
is associated with retained placental tissue. Ultrasound Obstet

Gynecol, 28; 3:312-9.
Mulic-Lutvica A, Bekuretsion M, Bakos O, et al. (2001): Ultrasonic

evaluation of the uterus and uterine cavity after normal, vaginal
delivery. Ultrasound Obstet Gynecol, 18: 491–498
Mulic-Lutvica A. (2007): Postpartum ultrasound. Acta universitatis

upsaliensis Uppsala. Available at http://www.diva-
portal.org/smash/record.jsf?pid=diva2%3A170138&dswid=-
5055.
Mulic-Lutvica A. (2012): Postpartum ultrasound. Donald School Journal

of Ultrasound in Obstetrics and Gynecology, 6; 1:76-92.
Müngen E. (3002): Vascular abnormalities of the uterus: Have we recently

over-diagnosed them? Ultrasound Obstet Gynecol, 21; 6:529-31.
Nanjundan P, Rohilla M, Raveendran A, et al. (2011): Pseudoaneurysm

of Uterine Artery: A Rare Cause of Secondary Postpartum
Hemorrhage, Managed with Uterine Artery Embolisation. J Clin
Imaging Sci, 1: 14.
Negishi H, Kishida T, Yamada H, Hirayama E, Mikuni M, Fujimoto

S. Changes in uterine size after vaginal delivery and cesarean
section determined by vaginal sonography in the puerperium.
Archives of gynecology and obstetrics. 1999 Dec 1;263(1-2):13-6.
Newsome J, Martin JG, Bercu Z, et al. (2017): Postpartum Hemorrhage.

Tech Vasc Interv Radiol, 20; 4:266-273.
89
REFERENCES
Nikolajsen S, Løkkegaard ECL and Bergholt T. (2013): Reoccurrence

of retained placenta at vaginal delivery: an observational study.
Acta Obstet Gynecol Scand, 92; 4:421–425.
Olayemi O, Omigbodun AA, Obajimi MO, et al. (2002): Ultrasound

assessment of the effect of parity on postpartum uterine involution.
J Obstet Gynaecol, 22; 4:381-4.
Olsen MA, Butler AM, Willers DM, et al. (2010): Risk Factors for
Endometritis Following Low Transverse Cesarean Section. Infect
Control Hosp Epidemiol. 2010 Jan; 31(1): 69–77.
Paliulyte V, Drasutiene GS, Ramasauskaite D, et al. (2017):

Physiological Uterine Involution in Primiparous and Multiparous
Women: Ultrasound Study. Obstet Gynecol Int, 2017:6739345.
Pather S, Ford M, Reid R, et al. (2005): Postpartum curettage: An audit

of 200 cases. Aust N Z J Obstet Gynaecol, 45; 5:368-71.
Perlman NC and Carusi DA. (2019): Retained placenta after vaginal

delivery: risk factors and management. Int J Womens Health. 2019;
11: 527–534.
Pessel C and Tsai MC. (2013): Chapter 10. The Normal Puerperium. In.
DeCherney, Alan H., and Lauren Nathan. Current diagnosis &
treatment obstetrics & gynecology. 11th edition. McGraw-Hill Inc.
p: 190 – 213.
Petrovitch I, Jeffrey RB, Heerema-McKenney A. (2009): Subinvolution

of the Placental Site. Journal of Ultrasound in Medicine, 28; 8:1115
– 19.
90
REFERENCES
Polat P, Suma S, Kantarcý M, et al. (2002): Color Doppler US in the

Evaluation of Uterine Vascular Abnormalities. Radiographics, 22;
1:47-53.
Rodeck CH, Newton JR. Study of the uterine cavity by ultrasound in the
early puerperium. Br J Obstet Gynaecol 1976;83(10): 795–801.
Rodgers SK, Kirby CL, Smith RJ, et al. (2012): Imaging after cesarean
delivery: acute and chronic complications. Radiographics, 32; 6:
1693–1712.
Shaamash AH, Ahmed AG, Abdel Latef MM, et al. (2007): Routine
postpartum ultrasonography in the prediction of puerperal uterine
complications. Int J Gynaecol Obstet, 98; 2:93-9.
Shalev J, Royburt M, Fite G, et al. (2002): Sonographic evaluation of the

puerperal uterus: correlation with manual examination. Gynecol
Obstet Invest, 53; 1:38-41.
Sokol ER, Casele H and Haney EI. (2004): Ultrasound examination of

the postpartum uterus: what is normal? J Matern Fetal Neonatal
Med, 15; 2:95-9.
Sokol ER, Casele H, Haney EI. Ultrasound examination of the

postpartum uterus: what is normal? J Matern Fetal Neonatal Med
2004;15(02):95–99
Tandberg A, Albrechtsen S, Iversen O. (9111): Manual removal of the

placenta, Incidence and clinical significance. Acta Obstet Gynecol
Scand, 78; 1:33–6.
91
REFERENCES
Timmerman D, Wauters J, S. Van Calenbergh S, et al. (2003): Color

Doppler imaging is a valuable tool for the diagnosis and
management of uterine vascular malformations. Ultrasound Obstet
Gynecol, 21; 6:570-7.
Üçyiğit A and Johns J. (2016): The postpartum ultrasound scan.

Ultrasound, 24; 3:163-169.
Üçyiğit A and Johns J. (2017): Imaging of Postpartum Uterine Pathology:

A Review. Int J Gynecol Clin Pract, 2: 136 – 145.
Urner F, Zimmermann R and Krafft A. (2014): Manual removal of the

placenta after vaginal delivery: an unsolved problem in obstetrics.
J Pregnancy, 2014:274651.
Van den Bosch T, Van Schoubroeck D, Lu C, et al. (2002): Color

Doppler and gray-scale ultrasound evaluation of the postpartum
uterus. Ultrasound Obstet Gynecol, 20; 6:586–591.
Van Rees D, Bernstine RL, Crawford W (1981) Involution of the

postpartum unterus:an ultrasonic study. J Clin Ultrasound 9:55–57.
Voorhorst MJ1, van Brederode JC, Albers-Wolthers CH, et al. (2013):

Successful treatment for subinvolution of placental sites in the bitch
with low oral doses of progestagen. Reprod Domest Anim, 48;
5:840-3.
Wachsberg RH, Kurtz AB, Levine CD, Solomon P, Wapner RJ (1994)

Real-time ultrasonography analysis of the normal postpartum
uterus: technique, variability, and measurements. J Ultrasound Med
13:215–221.
92
REFERENCES
Wataganara T, Phithakwatchara N, Komoltri C, Tantisirin P, Pooliam

J, Titapant V. Functional three-dimensional sonographicstudy of
the postpartum uterus. J Matern Fetal Neonatal Med
2015;28(18):2221–2227
Weydert JA and Benda JA. (2006): Subinvolution of the placental site

as an anatomic cause of postpartum uterine bleeding: a review.
Arch Pathol Lab Med. 2006 Oct;130(10):1538-42.
World Health Organization “WHO” Task Force on Methods for the

Natural Regulation of Fertility.. (1998): The World Health
Organization Multinational Study of Breast-feeding and
Lactational Amenorrhea. II. Factors associated with the length of
amenorrhea. World Health Organization Task Force on Methods
for the Natural Regulation of Fertility. Fertil Steril. 1998
Sep;70(3):461-71.
Yancey JD, Scioscia EA, Windle ML, et al. (2016): Dilation and
Curettage With Suction.
https://emedicine.medscape.com/article/1848296-overview.
Zelop C and Heffner LJ. (2004): The downside of cesarean delivery:

short- and long-term complications.Clin Obstet Gynecol, 47;
2:386-93.
93
‫الملخص العربي‬
‫الملخص العربى‬
‫مقدمة‪:‬‬
‫النفاس‪ ،‬هو تلك الفترة التى تلى الحمل والوالدة وفيها يستعيد الجسم حالته الطبيعية‬
‫وذلك بعد التغييرات التى تطرأ عليه فى فترة الحمل واالدة‪،‬كما يبدأ الرحم لحالته ما قبل الحمل حيث‬
‫يخضع لعددمن التغيرات فى الشكل والحجم والمكونات والمكان‪ ،‬والممكن أن تحدث العديد من‬
‫التغيرات المرضية كعدوى الرحم التى تسبب حمي النفاس والنزيف‪ ،‬وتعد هذه التغيرات من األسباب‬
‫الرئيسية لوفيات األمهات فى جميع أنحاء العالم ولذلك يعتبر التشخيص المبكر لها ذو ظاهمية‬
‫قصوي‪.‬‬
‫ً‬
‫سابقا كان يتم متابعة تلك التغييرات عن طريقة متابعة وجس مستوي ارتفاع الرحمز‬
‫وكانت تواجه هذه الطريقة العديد من الصعوبات خاصة فى هؤالء النسوة الالتى يعانون من البدانه‬
‫او وجود اورام ليفية بالرحم‪ .‬ومع استخدام التصويرباستخدام بالموجات فوق الصوتية فى فحص‬
‫الرحم قبل واثناء وبعد الحمل الوالدة توافرات تقنية اكثر دقة وفعالية ومنخفضة التكلفة وأكثر‬
‫ً‬
‫قبواال من السيدات فى متابعة التغييرات الديناميكية التى تحدث للرحم‪.‬‬
‫الهدف من البحث ‪:‬‬

‫هدفت هذه الدراسة إلى إجراء مقارنة التغييرات التى تحدث للرحم فى اليوم السابع واليوم‬
‫األربعين بعد الوالدة الطبيعية والوالدة القيصرية باستخدام التصويربالموجات فوق الصوتية‪.‬‬
‫طرق البحث‪:‬‬
‫اشتملت هذه الدراسة على عدد ‪ 126‬من السيدات الالتى خضعن للوالدة بقسم التوليد‬
‫وأمراض النساء بمستشفيات جامعة الزقازيق حيث تقسيمهم إلى جموعتين‪:‬‬
‫املجموعة األولي‪ :‬واشتملت على ‪ 11‬من السيدات الالتي خضعن للوالدة الطبيعية‪.‬‬ ‫‪‬‬
‫املجموعة الثانية‪ :‬و اشتلمت على ‪ 11‬من السيدات الآلتي خضعن للوالدة القيصيرية‪.‬‬ ‫‪‬‬
‫‪1‬‬
‫وقد خضعت جميع المشاركات بالدراسة لإلجراءات اآلتية وذلك بعد الحصول على موافقة‬
‫كتابية منهم على الشترا فى الدراسة‪:‬‬
‫أخذ التاريخ المرض ي الكامل للسيدة وللحمل وتاريخ أخردورة والوالدت السابقة‬ ‫‪‬‬
‫فحص طبي عام وشامل‪.‬‬ ‫‪‬‬
‫الفحوصات المعملية‪ :‬لما قبل الوالدة وقد تضمنت صورة دم كاملة‪ ،‬وظائف كبد وكلى‪.‬‬ ‫‪‬‬
‫وقت بدأ الرضاعة الطبيعية‪.‬‬ ‫‪‬‬
‫الفحص باتخدام الموجات فوق الصوتية وذلك في اليوم السابع واليوم األربعين بعد الوالدة‪.‬‬ ‫‪‬‬
‫نتائج البحث‪:‬‬
‫‪ )1‬اظهرت النتائج وجود اختالف ظاهري بين املجموعتين فى عمر الحمل عند الوالدة حيث كان عمر‬
‫ً‬
‫الحمل اكثر من ‪ 93‬اسبوعا فى حوالى ‪ %07‬من السيدات الالتى خضعن للوالدة الطبيعية بينما‬
‫ً‬
‫‪ %21‬من السيدات الالتى خضعن للوالدة القيصيرية كان عمرالحمل فيهن حوالى ‪ 91‬اسبوعا‪.‬‬
‫‪ )6‬أظهرت النتائج عدم وجود اختالف ظاهري بين املجموعتين من حيث عدد السيدات التى قمن‬
‫بالرضاعة الطبيعية أو توقيت بدأ الرضاعة الطبيعية‪.‬‬
‫‪ )9‬أظهرت النتائج وجود اختالف ظاهري بين املجموعتين فيما يخص عرض الرحم ولكن مع اليوم‬
‫األربعين اختفي هذا الختالف‪.‬‬
‫‪ )4‬أظهرت النتائج وجود اختالف ظاهري بين املجموعتين فيما يخص طول الرحم ولكن مع اليوم‬
‫‪ )5‬أظهرت النتائج وجود اختالف ظاهري بين املجموعتين فيما يخص القطر األمامى الخلفي للرحم‬
‫واستمروجود هذا االختالف مع اليوم األربعين‪.‬‬
‫‪2‬‬
‫‪ )2‬أظهرت النتائج وجود اختالف ظاهري بين املجموعتين فيما يخص تجويف الرحم ولكن مع اليوم‬
‫‪ )0‬اظهرت النتائج وجود اختالف ظاهري بين السيدات الالتى خضعن للوالدة الطبيعية وقمن‬
‫بالرضاعة الطبيعية وهؤالء الالتى لم تقمن بالرضاعة الطبيعية فيما يخص جميع أبعاد الرحم‪.‬‬
‫‪ )1‬اظهرت النتائج وجود اختالف ظاهري بين السيدات الالتى خضعن للوالدة القيصيرية وقمن‬
‫بالرضاعة الطبيعية وهؤالء الالتى لم تقمن بالرضاعة الطبيعية فيما يخص جميع أبعاد الرحم‪.‬‬
‫‪3‬‬

الرسالة كاملة

Uploaded by

Copyright:

Available Formats

You might also like

الرسالة كاملة

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

الرسالة كاملة

Uploaded by

Copyright:

Available Formats

Zagazig University

COMPARISON BETWEEN NORMAL LABOR AND CESAREAN

‫أمل محمد األنور‬ ‫محمد نجيب عزام‬

‫وائل صبري نصير‬

‫كلية الطب البشري‬

- Aim of the work 3

Chapter (I): Physiological And Anatomical Changes

Chapter (II): Uterine Evaluation During Normal And

Chapter (III): Normal Postpartum Findings On

- Conclusion and Recommendation 80

AVMs Arteriovenous Malformations

CBC Complete Blood Count

IUM Intrauterine mass

NVD Normal vaginal delivery

PPH Primary postpartum hemorrhage

PSV Peak systolic velocity

RPT Retained Placental Tissue

SPH Secondary postpartum hemorrhage

Table (1) Socio-demographic data of the two studied groups 53

The uterus after birth undergoes several changes in size, shape,

Primary and secondary post-partum hemorrhage and post-partum

Placental tissue remaining inside the uterus after labor is associated

It would be important to know the normal US shape of the uterus

Our knowledge about postpartum changes in the uterus has mainly

The involution of the uterus which is a main feature of the

Since the introduction of US in clinical work by Ian Donald et al.

Doppler ultrasound was used to measure flow resistance indices of

AIM OF THE WORK

PHYSIOLOGICAL AND ANATOMICAL

As regard to the uterus; there is enormous growth of the uterus

This increase in growth and enlargement of the body of the uterus

Figure (1): Schematic presentation of the longitudinal, oblique and circular

The uterine enlargement is not a symmetrical one; the fundus

The normal anteverted position of the uterus is exaggerated up to 8

incapable of filling, clinically evident by frequency of micturition.

As the uterus enlarges to occupy the abdominal cavity, it usually

Whereas in the non-pregnant state, the blood supply to the uterus is

During normal pregnancy a large network of new vessels in the

During the first trimester, isthmus hypertrophies and elongates to

Physiology Of Uterine Involution Postpartum

The postpartum period, also known as the puerperium, begins with

Most of the physiologic changes in pregnancy will have returned to

Immediately after delivery of the placenta, the uterus begins to

A main characteristic of the puerperium is this uterine involution,

After delivery, the fundus is normally firm, nontender, globular,

decreases from approximately 1000 g immediately postpartum to 60 g six

After delivery there is a rapidly decreasing endometrial surface area

diameter of the site of placental attachment measures 9 cm (Antony et al.,

The initially remaining spongy and superficial layers of the

An area of viable decidua remains between the necrotic slough and

The postpartum endometrium regenerates at a rapid pace; at day 7

Normal shedding of blood and decidua is referred to as lochia rubra

The total volume of postpartum lochia secretion is 200 to 500 mL,

During pregnancy, the cervical epithelium increases in thickness,

Uterine Pathophysiology During The Puerperium

The process of uterine involution, which is one of the main

Vaginal bleeding that persists for more than approximately eight