Ultrasound Obstet Gynecol 2001; 18: 491– 498

Ultrasonic evaluation of the uterus and uterine cavity after
Blackwell Science Ltd

normal, vaginal delivery
A. MULIC-LUTVICA, M. BEKURETSION, O. BAKOS and O. AXELSSON
Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

K E Y WOR D S: Human pregnancy, Normal puerperium, Ultrasound, Uterus

puerperium and in the whole uterine cavity in the middle part
ABSTRACT
of the puerperium. Findings from uncomplicated vaginal
Objective To describe uterine and uterine cavity changes deliveries are needed as a reference when the diagnostic efficacy
throughout the puerperium, as revealed by ultrasound. of ultrasound for pathological conditions is to be tested.
Methods This was a prospective, longitudinal study in which
42 women with uncomplicated vaginal term deliveries were
INTRODUCTION
examined serially by ultrasound on postpartum days 1, 3, 7,
14, 28 and 56. The first four examinations were performed The puerperium is defined as the period of 6–8 weeks after
transabdominally and the last two transvaginally. The delivery during which the uterus, which weighs more than
involution process of the uterus was assessed by measuring 1 kg soon after delivery, undergoes physiological involution
the anteroposterior diameter of the uterus and uterine cavity. and returns to the non-pregnant state. Our previous knowledge
Morphological findings were recorded. The influence on the about the puerperal uterus is mainly based on histological
involution process of parity, breast-feeding, maternal smoking studies obtained from postmortem examination when maternal
and infant’s birth weight were also evaluated. death during the puerperium was commonplace1. The involu-
tion process of the uterus as a main characteristic of the puer-
Results The maximum anteroposterior diameter of the uterus
perium was previously assessed by palpation of fundal height,
diminished substantially and progressively from 92.0 mm on
which can be difficult in obese women and in women with
day 1 postpartum to 38.9 mm on day 56. The maximum
uterine myoma2.
anteroposterior diameter of the uterine cavity diminished
Although the uterus was one of the first organs to be
from 15.8 mm on day 1 to 4.0 mm on day 56. However, the
examined by ultrasound when ultrasound was introduced
anteroposterior diameter of the uterine cavity, 5 cm from the
into clinical practice by Donald et al.3 only a few ultrasound
fundus, typically increased on days 7 and 14 postpartum. The
studies have involved investigations during the puerperium4–9.
position of the uterus and the shape and the appearance of the
In the majority of previously published studies, old com-
cavity change in a unique way during the normal puerperium.
pound scanners with poor image resolution were used. The
The uterus was most often retroverted and empty in the early
actual timing of measurements is rarely specified. More-
puerperium. Fluid and debris in the whole cavity were seen
over, the examinations were most often restricted to the
in the middle part of the puerperium. In late puerperium the
early puerperium7–12 and only one study was longitudinally
cavity was empty and appeared as a thin white line.
designed13. There is disagreement concerning the influence on
Endometrial gas was occasionally visualized. No correlation
the involution process of parity7–9,14–16 breast-feeding8,9,11,14,16
was found between the involution of the uterus and parity,
or the infant’s birth weight8,11,16. There are also confusing
breast-feeding and the infant’s birth weight.
data about the presence of gas10,12,17 fluid or echogenic masses
Conclusion Transabdominal sonography is suitable for in the cavity during the normal puerperium.
examination of the uterus during the first 14 days postpartum A description of normal ultrasonic changes of the uterus in
but from day 28 the transvaginal route is preferable. The the puerperium is a prerequisite for ultrasound diagnosis of
uterine body and position, as well as the cavity, are easy to pathological conditions. It should be useful to know the normal
examine by ultrasound. Accumulation of fluid and debris in ultrasound appearance of the uterus throughout the entire
the uterine cavity is a common and insignificant finding of the puerperal period in order to improve our ability to distinguish
involuting uterus. It is located in the cervical area in the early puerperal pathology from normal conditions and thus avoid

Correspondence: Dr A. Mulic-Lutvica, Department of Obstetrics and Gynaecology, University Hospital, SE 751 85 Uppsala, Sweden
(e-mail: ajlana.mulic-lutvica@kk.uas.lul.se)
Received 1-8-00, Revised 18-6-01, Accepted 1-8-01

ORIGINAL PAPER 491

Moreover. Seven women developed puerperal pathology. 1997. Seven did not wish to participate. singleton pregnancies with a term vaginal delivery and an uneventful puerperal course.6 mm on day 1 to 9. were measured. The ultrasound examinations were scheduled for days 1. The study was approved by the ethics committee of the medical faculty of Uppsala University.1 mm on day 56 scan (b) and a coronal scan (c). 2640–4510) g. 19–41) years. decreased from 15. The coronal sec- tion was analyzed in order to exclude uterine malformations.5-MHz transabdominal convex probe and a 5-MHz vaginal probe. Erlangen. breast-feeding or maternal smoking.0 mm on day 56. Twenty-two were breast-feeding their infants. The same measurements were also made at a distance of 5 cm from the uterine fundus. as were the pres- ence of fluid.0 mm on day the uterine involution process was influenced by parity. NC.Ultrasound in puerperium Mulic-Lutvica et al. Sweden. day 56. Mountain View. Tender compression by the probe was used and the measurements were made between uterine contractions. All 42 women had uncomplicated. Informed consent was obtained from all women recruited into the study. 56. and 56 after delivery. Germany.5 mm on day 1 to 28. Thus. Cary. Tables 2 and 3 summarize the qualitative Figure 1 Transabdominal ultrasound scans of a normal puerperal parameters of the uterus and uterine cavity. USA. Tokyo. 492 Ultrasound in Obstetrics and Gynecology .. The median age of the women was 28 (range. RESULTS Table 1 summarizes the measurements of the uterus and uterine cavity. USA. All ultrasound examinations were performed with com- mercially available real-time machines (Acuson 128. The form and position of the uterus were recorded.2 mm on day 7. The women had a moderately filled urinary bladder when examined. 42 women remained in the study. For the first four examinations a transabdominal probe was used and for the last two a trans- vaginal probe was used.0 mm on day 1 to 38. The median birth weight of the infants was 3545 (range. perpendicular to the endometrium. heterogeneous contents. 7. The quantitative variables were analyzed utilizing the JMP from the SAS statistical package (SAS Institute Inc. In the longitudinal section the maximum anteroposterior (AP) diameters of the uterus and uterine cavity. whereas 20 used bottle-feeding. CA. The mean of the maximum AP diameter of the cavity infant birth weight. The uterus was assessed in the longitudinal. uterus on day 1: a longitudinal scan (a) (angulated form of the uterus was The mean AP diameter of the uterus 5 cm from the fundus avoided by semireclining position of examined woman). unnecessary invasive procedures. Eighteen were primiparous and 24 were multiparous. The MATERIAL AND METHODS Sixty women were asked to participate in the study between 1996 and 1998. A secondary aim was to see if after the diameter decreased continuously to 2. 14. the knowledge postpartum (Table 1). Five women were smokers and 37 were non-smokers. JMP Version 3. Four women took part only in the first ultrasound examination. Siemens sonoline SI-400.8 mm on day 1 to 4. There- uneventful puerperal course. or gas in the uterine cavity. term delivery and increased from 6.2). Comparisons between groups were carried out using the t-test.9 mm on understand the physiology of the puerperium. Our aim was to describe the uterine and uterine cavity The mean AP diameter of the cavity 5 cm from the fundus changes after a vaginal. 28. Japan) with a 3. Toshiba Sonolayer Capasee SSA. The maximum AP diameter of the obtained through ultrasonic examinations can help us to better uterus decreased from 92. transverse and coronal sections (Figure 1). 3. a transverse decreased from 83. uncomplicated.

The maximum diameter on days 7.0 (6. The content was either fluid or had a hetero. The endometrium appeared 39 (92.7. 2 15.7.1.0 4.8 (10. It was more oval and anteverted geneous pattern with solid and fluid components filling the in 30 of 41 (73. A schematic summary of the uterine and uterine cavity The cervical area was empty in nine of 42 women (21.4) 2/41 (4. On day 3 it had disappeared. on day 28 in 31 of 39 (79.8) 5/42 (11.7–18) (4. range)) Cavity AP diameters (mm) (Mean (SD.3) 36/41(87.7) (5. 68.4–21) 56 28.5 –101) (9. (Figure 3c).7.2 3. 14. separated this endometrial line (Figure 5b). 48 – 86) (7.8%) women (Figure 5c).6 63. 2.0 6.4.1 (7.1%) on day 3 (Table 2). plane was angulated and the position was retroverted in 40 Table 3 shows that the majority of women had some content of 42 women (95. the middle part of the puerperium in four of 41 women on The normal shape of the early puerperal uterus in the sagittal day 7 (9. on day 1.6 15. 36.4%).8–61) (2. During late puerperium an empty cavity was anteverted in 39 of 41 (95.2 – 41.1) 36/39 (92. 1.3 – 98) (9. 33 of 42 (78.5 (8. 56 in 39 of 41 (95.4 5.2%). 0.9%) had scanty amounts of more heterogeneous pattern was seen in three of 42 women particulate matter. 29. The cavity was seen as a con. of the uterus had changed.5%) women and on day cavity diameters.2–44) 14 59.2) 39/41 (95. An empty cervical area was seen on day 14 in 37 of 41 women Figure 2 shows graphs of individual data of the uterine and (90.7 13.2 (10. 2. During early puerperium the cavity was empty in 39 of 42 A minor hyperechogenic focus in the cavity was seen in two women on day 1 (92. range)) Postpartum day 5 cm from fundus Maximum 5 cm from fundus Maximum 1 83.9–6.5.6%) had a No correlation was found between the different measure- collection of fluid with mixed echo pattern in the cervical area ments and parity. the cervical area was empty.4%) changes throughout the puerperium is shown in Figure 6.5–36) 7 69.9.9.2 – 93.9.9.6 – 58) (5.2.4.3%) women (Figure 5a). 47. The majority of women. anteroposterior.4) 22/42 (52.4.3. 3.9%) (Figure 3a) and in 35 of 42 women of 42 women (4.6.3) (3.1) (8. maximum diameter of the cavity was found in the lower uterine cavity including the cervical area in a majority of women and segment on days 1 and 3.2) 3 79.3) 4/41(9. On was found in 29 of 39 (74. The uterus had an anteverted posi- women on day 28. Women who smoked had slightly Table 1 Uterine and uterine cavity dimensions during a normal puerperium Uterine AP diameters (mm) (Mean (SD. 58.1%) women (Figure 4b).2) 31/39 (79.5 92. In 10 of 39 (26%) process was completed. In one case a reverberation artifact was (7.6.4%) had a hyperechogenic tinuous white line along the entire uterine cavity from the focus.9 2.9 9.8) 10/41 (24.0) (2.3%) women this was expelled Although the AP diameters of parous women were somewhat and an empty cavity was seen on the following day.4.Ultrasound in puerperium Mulic-Lutvica et al.3%) (Figure 3d). 21.1.1) Gas/hyperechogenic foci (n (%)) 2 /42 (4.2. An empty cavity was found during seen (Figure 4c) which disappeared by day 28.1%) on day 1 (Figure 3b).8%) on day 1.8) Missing (n) 0 0 1 1 3 1 Total (n) 42 42 41 41 39 41 Ultrasound in Obstetrics and Gynecology 493 .1 9.8–33) (8.5–22) 28 42.0 49. On day 14 the uterus whole cavity (Figure 4).4–50) (0.5 87. in just nine of 41 (22%) women. 18. In 22 of 42 (52. on day 3 (83. 50–86) (4.1) 1/41 (2.1) Empty cervical area (n (%)) 9 /42 (21.9) 35/42 (83. 0.2.5–109) (4.4.9–16.9–37) (8.2%) women (Figure 4a). 0. internal cervical os to the top of the fundus. 61.4%) women on day 28 and in 39 day 28 an anteverted position of the uterus was seen in 36 of of 41 (95. On day 7 the shape and the position on days 1 and 3. On day 56 the involution as a thin white line (Figure 5a and c). Table 2 Qualitative findings in the uterus and uterine cavity during a normal puerperium Postpartum day Finding 1 3 7 14 28 56 Empty cavity (n (%)) 39 /42 (92.5–45.9) 2/39 (5.7.1 38. independently of the cavity status (88.4) 39/41 (95.3) 9/41(22.1%) women on day 56.2 6.2 (9. which was observed on each of the following occasions.8%) and in 10 of 41 women on day 14 (24.7–11) (2. 28 and 56 was found in the middle part of the uterine cavity.6.1%) women. 0. 1. infant’s birth weight or breast-feeding.4 7.3–94) (6.8) 0/42 (0) 1/41 (2. the difference was 7 the cavity contained fluid or there was debris in the whole not statistically significant.0) 37/41 (90.2%) on day 1 and in 37 of 42 women in the cavity on days 7 and 14. 3.9 74.9) 30/41 (73.8. 1–10) AP. On day larger than those of nulliparous women.4) Anteverted uterus (n (%)) 2 /42 (4. 70–109.4) 29/39 (74. 64. a minimal amount of fluid or echogenic dots tion in 36 of 41 (87. A thicker and On day 14 two of 41 women (4. 0.5) 39/41 (95. On day 7 one of 41 women (2.7) (7.

higher maximum AP diameters of the uterus (P = 0. Length7. width10. However.0432).14–16. AP diameter9. A recently published study by Sakki and Kirkinen was restricted to the early puerperium12. However.13–16. 494 Ultrasound in Obstetrics and Gynecology .9–11. The accurate timing of measurements is not always specified. Most studies are cross-sectional and old compound scanners were used4–9. b) and uterine cavity (c. DISCUSSION Since its introduction into obstetric practice3 ultrasound has made non-invasive investigation of the uterus possible. attention was focused on puerperal hemodynamic changes13.11.14–16. only five women were smokers. In a report by Tekay and Jouppila. previously published studies involving sonographic examination of the puerperal uterus are not unambigu- ous4–11.16 and area14 Table 3 Individual findings in the uterine cavity during a normal puerperium Empty cavity (yes/no) on postpartum day Case 1 3 7 14 28 56 1 y y n n y y 2 y y n n y y 3 y y n y y y 4 y n n n y y 5 y y y n n y 6 y y n n y y 7 y y n y y y 8 y y n n y n 9 y y n n n y 10 y y n n n y 11 y y y n n y 12 y y n n n y 13 y n n n y y 14 y y y y y n 15 y y n y y y 16 y y n n y y 17 y y n n n y 18 y n n n y y 19 y y n n y y 20 y y n n y y 21 y y y n y y 22 y y n n y y 23 y y n y y y 24 y y n n y y 25 y y n n y y 26 n n n n n y 27 y y n y y y 28 y y n n y y 29 y y n n n y 30 y y n n n y 31 y y n n y y 32 y y n n y y 33 n n n n n y 34 y y n y y y 35 y y n y y y 36 y y n n y y 37 y y n y y y 38 n n n y y — 39 y n — n y y 40 y y n n — y 41 y y n n — y Figure 2 Individual uterine (a. There are also conflict- ing data about the best indicator of the involution process. d) measurements 42 y y n — — y throughout the puerperium.Ultrasound in puerperium Mulic-Lutvica et al.

which can be due to a of a longitudinal design. contractions. b. we preferred to use the These findings are in accordance with previous reports15. It lies in a slightly retroverted position and arches over During the first 3 days postpartum the cavity is very thin. the transvaginal tudinal section seems to be a suitable measurement with approach is preferable. the sacral promontory. On these occasions. 3. part of the puerperium. form. The thickness of a heavy corpus. In 12% of our cases the uterus be recommended.15.19. in (c) a heterogeneous echo pattern is seen with solid and fluid components in the cervical area. It rotates about 100–180° along the internal involution changes are best revealed and described by means os towards an anteverted position. transabdominal approach during the first four examinations. In our and 56 postpartum. it is easy to obtain On days 1 and 3 postpartum the uterus has an angulated and is only marginally subjected to distortion. in (b) the cavity is thicker and shows a more heterogeneous pattern.11. c) and day 3 (d). a relatively and progressively during the puerperium and reached non- short focal length limits its use during the early and middle pregnant dimensions between 4 and 8 weeks postpartum.15. On day 1. In contrast. This artifact can be avoided of studies8. the uterus lies in the true pelvis and is opinion. and the formation In the early puerperium the transabdominal approach is to of a firm isthmus (Figure 6). Wachsberg less decidua can be retained1. the maximum AP diameter in the longi- markedly decreased in size. Ultrasound in Obstetrics and Gynecology 495 . This position of the uterus is probably due to metrium. Therefore. More or with the supine position of the examined women.20 and after normal deliveries Figure 3 Transabdominal. longitudinal scans of the uterus from an uncomplicated puerperium on days 1 (a. of the uterus have been used. which to estimate the involution process. a hypotonic lower segment in combination this line depends on the amount of retained decidua. Although a high frequency trans. The walls are in close proximity. the whole cavity is seen as a thin white line. in (a). 7 and 14 postpartum.10. Between days 7 and 14 the shape of the the entire puerperium. In our opinion the regularity of the uterus is oval. The angulation is situated just above probably due to the lifesaving contractions of the myo- the internal os. decrease in size of the uterus. Defoort et al. As regards the uterine cavity. there is a notable lack measurements of uterine length. on days 28 appropriate parameter for assessing the involution.18. A large uterus cannot be imaged properly remained in a retroverted position. as well as thickness of the uterine et al. The AP diameter of the uterus diminished substantially vaginal probe may better distinguish minor details.Ultrasound in puerperium Mulic-Lutvica et al.16 pointed out the impact of uterine angulation on the wall10. We chose a longitudinal study where each if the woman is in a semireclining position during the exam- woman was examined on six different occasions throughout ination (Figure 1a). using a transvaginal probe. however.9 concluded that the AP diameter is not an on days 1.

in (b). 496 Ultrasound in Obstetrics and Gynecology . The endometrium is solid components is seen in the whole cavity. whereas the thicker and more irregular lines components was only seen in the cervical area. in (a). bright line. The bright thin line seen on ultrasound puerperium it is uncommon to find fluid or an echogenic might possibly represent cases in which only the basal decidual mass in the cavity. b) and 56 (c). The is seen in the lower uterine segment. in (b). the uterus seen as a thin. fragments of membranes. On day 28. the involution process is completed and cavity. a small amount of fluid separates the has an oval shape and is anteverted and fluid is seen in the whole uterine uterine walls. the variation in sonographic appearance of the cavity could might represent cases with retention of the spongy decidual be seen as a demonstration of these physiological variations layer and. endometrium is seen as a thin. In the early in retained decidua. On day 14. On day 56. probably Figure 4 Transabdominal. a hyperechogenic focus (arrow) with reverberation artifact the uterus has achieved non-pregnant dimensions and appearance. in (c). longitudinal scans of the uterus during Figure 5 Transvaginal scans of the uterus during normal puerperium on uncomplicated puerperium on days 7 (a) and 14 (b. the uterus has an oval shape uterus is oval. perhaps. anteverted and a heterogeneous pattern with fluid and and an anteverted position and the cavity is empty. bright line. in (c). On day 7. A mixed echo pattern with fluid and solid layer is retained. the days 28 (a.Ultrasound in puerperium Mulic-Lutvica et al. c).

Wachsberg and Kurtz detected gas in the puerperium. Shaw LA. Am J Obstet Gynecol 1993. 17 Wachsberg RH.18. 80: 320–4 6 Stone M. 17: 364 which separates the uterine walls.15. Our 1 Hytten F. Previous 13 Tekay A. Obstet cavity after normal vaginal delivery and that it always disappears Gynecol 1981. Kiss D. apart from the cervix. 168: 190–7 about 21% of a normal population17. Solomon P. Campbell S. 1: 1188 probably due to the presence of a necrotic decidual cast 4 Robinson HP. In the early puerperium thin white line in the upper part. The presence of hyperechogenic dots 16 Wachsberg RH. Levine CD. The use of the ultrasonic echo technique in exam- endometrium seen during menopause or the early prolifera. A longitudinal Doppler ultrasonographic studies have suggested a correlation between gas and infection assessment of the alterations in peripheral vascular resistance of uterine caused by Escherichia coli and Clostridium perfringens10. Jouppila P. and reflects the completed J Gynaecol Obstet 1976.15. Lancet 1958. Our results 9 Defoort P. James AE. Investigation of abdominal masses echo patterns were seen in the whole cavity. Kurtz AB. J Obstet Gynaecol Br Com- lochia. It was found in a majority of women even when the monw 1973. 4: 99–105 or dirty shadowing or a reverberation artifact17. 1996 Increased values of the cavity diameters were measured 2 Beazley JM. The cervical area is expanded with fluid the cavity. reflecting a normal healing 5 Malvern J. Brown TC. On days 28 plications after vaginal termination of pregnancy. for financial support. membranes (Figure 3c). J Clin Ultrasound 1981. Madrazo B. It can be noted that the uterus ACKNOWLEDGMENTS rotates about 100 –180° along the internal cervical os from a retroverted position on days 1 and 3 (a) to a mid-position on day 7 (b) to an We are grateful to the Ultrasound Foundation at the Depart- anteverted position on days 14 (c). Involution of the postpartum uterus. 8: 481–6 genic focus equivalent in echogenicity to bowel gas with clean 12 Sakki A. Radiology 1992. Endometrial fluid or a heterogeneous pattern 795–801 are rare findings during the late puerperium. Underhill RA. (c) Day 14: The uterus is anteverted late puerperium. 9: 55 not been able to confirm this to any particular extent12. (d) Days 28 and 56: Uterus is considerably decreased in size. Int tive phase of the menstrual cycle. Scott Med J 1972. Wapner RJ. 58: 227–32 within 1 or 2 weeks24. ining the normal and pathological involution in the puerperium. 8: 95– accordance with histological studies of the puerperal uterus 7 10 Madrazo BL. Ultrasonography of the uterus at early puerper- ium. The same image is typical for the contents are seen in the whole cavity. 14: 513–6 8 Rodeck CH. This corresponds to an inactive 7 Szoke B. A normal finding after spontaneous vaginal delivery.22. Martens G. CONCLUSION (b) (a) (c) In spite of the great variations of the normal ultrasound appear- ance of the puerperal uterus some findings are representative (d) for early. and 28 and 56 (d). Uppsala University Hospital. Abundant fluid or mixed sound as a thin white line. ment of Obstetrics and Gynaecology. Thiery M. Ultrasonic evaluation of the post- Our results indicate that gas is occasionally seen in the uterine partum uterus in the management of postpartum bleeding. Eur J Ultrasound 1996. Ultrasonic scanning of the puerperal uterus process of the uterine cavity and an abundant shedding of following postpartum haemorrhage. This was usually expelled and was not seen on the following occasion. Accumulation of fluid and debris in the uterine cavity is a common and insignificant finding of the involuting uterus. In: Sanders RC.23. 11 Lavery JP. Eur J Obstet Gynaecol 1978. We also wish to thank Henric reflecting a collection of blood. 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