Ch 17 Postpartum Uterus Flashcards
Define puerperium?
-The postpartum period
-Time immediately following the expulsion of the placenta + uterine contents to 6-8 weeks after birth (or whenever the uterus regains its prenatal shape)
List 5 puerperium indications for scanning?
-Postpartum hemorrhage
-Search for causes of puerperal infection
-Evaluate for postpartum ovarian vein thrombophlebitis (POVT)
-RPOC
-Complications arising from c-section (ex. hematomas + abscesses at incision site)
Why do physiologic + biochemical changes occur in the postpartum period?
B/c of the withdrawal of pregnancy induced hormones:
-Causes uterus to return/involute back to prepregnancy state (occurs within 1 week of delivery)
Discontinuance of lactation results in what?
Resumption of ovulation + menstruation
It is common to image the internal os on day 1, what will it look like?
Partially open + ill-defined, as it continues to close following delivery
List the postpartum sonographic appearance of the myometrium + endometrium?
Myo: homogeneous, delineated, 7-10cm in thickness
Endo: thickened initially up to 13mm, but should decrease to normal thickness of 3-8mm by end of postpartum period
Why is free fluid in the endo cavity a normal finding in postpartum?
B/c blood + other substances slough off from uterus after birth
The endometrium should not measure greater than what in postpartum?
1.2-1.4cm or 12-14mm
What are the postpartum uterus measurements?
SAG: 14-25cm
TRV: 7-14cm
How will the ovaries look during pregnancy?
Should remain the same, except for a few more cysts seen in 1st trimester
Differentiate acute vs delayed hemorrhage?
Acute: severe bleeding immediately after delivery, m/c resulting in emergency hysterectomy
Delayed: bleeding that occurs over several days - a few weeks in postpartum period
Define a postpartum hemorrhage?
Blood loss of greater than 500 mL during the 3rd stage of labor OR right after a vaginal delivery
A C-section delivery requires how many mL loss to classify as a postpartum hemorrhage?
Over 1000 mL
What are the m/c causes of a postpartum hemorrhage?
Placenta accreta, increta + percreta
Define a puerperal infection?
Any infection in the postpartum period characterized by a temp over 100.4 F/38 C on any 2 days in a row after the first 24 hours postpartum
What is the first sign of postpartum infection?
Uterine tenderness (not “afterpains”)
Other symptoms:
-chills, headache, malaise, anorexia, vag discharge (lochia) may be diminished or profuse/odorous
What is the m/c puerperal infection?
UTI - but can also be breast infections, thrombophlebitis or endometritis
What is endometritis?
Infection of endo - m/c due to the migration of normal vaginal flora which may result in postpartum bleeding
What does VBAC stand for?
Vaginal birth after cesarean
What increases the risk of endometritis?
VBAC
SF of endometritis?
Thick, irregular endo with potential fluid in endocervical canal
(gas may be seen in endo canal, however after 3 weeks postpartum gas is a normal finding)
What is RPOC due to?
-Due to incomplete expulsion of products of conception during labor + delivery
-Can cause infection
(only 1% of term deliveries are complicated by RPOC)
SF of RPOC?
Highly echogenic mass in endo
Remnants of placental tissue is called what?
Placental polyps - they are due to incomplete placental expulsion from uterus (RPOC)
What does RPOC have a similar appearance to sonographically?
Endometritis
What is uterine atony?
When the uterus fails to reach pregravid tone + becomes flaccid and unable to hold its shape
(when uterus doesn’t tighten properly after birth)
What is one of the most frequent causes of postpartum hemorrhage?
Uterine atony
What women are at an increased risk for uterine atony?
Multifetal pregnancy, macrosomy, prolonged labor, >5 term pregnancies, rapid labor, polyhydramnios + chorioamnionitis
What is thrombophlebitis?
The inflammation of a vein caused by a thrombus in the lumen of the vessel
What does POVT stand for? When does this condition occur?
-Postpartum ovarian vein thrombophelebitis
-Rare condition found m/c in postpartum period, but can occur with malignancies + PID
The pathogenesis of POVT relates to what triad?
Virchow’s triad
The majority of cases of POVT involve the right or left ovarian vein?
Right
List the 3 m/c symptoms of POVT?
-Pelvic pain
-Fever
-Right sided pelvic mass
(experience these within 48-96 hours after delivery)
What is the gold standard for diagnosing POVT?
CT
SF of POVT?
Dilated anechoic - hypoechoic tubular structure extending superiorly from adnexa
Treatment of POVT?
IV therapy of anticoagulants (such as heparin + blood thinners like warfarin)
How were C-section incisions done traditionally vs how they are done now?
Traditionally: vertically along long axis of uterus
Nowadays: TRV incision
SF of a C-section scar?
Anechoic to hypoechoic, depending on how the tissue reacts to the surgery
What is a common complication of C-sections?
Hematomas at site of incision + infection
What is the area called where post cesarean hematoms typically develop?
Bladder flap - is a cut in the peritoneum b/w urinary bladder + uterus to access the lower uterine segment
What do C-section hematomas look like?
-Anechoic with ill defined borders ranging from <1cm to >15cm in size
-Can appear complex b/c of clotting, septations or debris within it
What 4 things could cause an infection after a C-section?
-Long operation time
-Endometritis
-Contaminated amniotic fluid entering incision
-Preexisting infections
(if pt has fever think infection)
Where do infections develop after a C-section?
In abdominal or uterine wall
How would C-section infections look?
Can range from anechoic, cystic, complex + with or w/o defined borders
(abscesses can develop along incision line which would look complex)
What is the alternate term for postpartum period?
Puerperium period
How long is the puerperium period?
6-8 weeks
