Download [ PDF ]
Send to a friend
Page Views(700)
Facebook Share
Twitter ShareEvaluation of Vascularity and Colour Doppler Blood Flow in Uterine Myometrium after Delivery.
Shideh Ariana1, Vajiheh Marsoosi2, Ashraf Jamal3, Mahsa Naemi4, Maryam Nurzade5, Maryam Maktabi6, Somayeh Khanjani7, Nasrin Mansouri8
1Department of Obstetrics and Gynaecology, Tehran University of Medical Sciences, Tehran, Iran. 2Department of Obstetrics and Gynaecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 3Department of Obstetrics and Gynaecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 4Department of Obstetrics and Gynaecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 5Department of Obstetrics and Gynaecology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 6Department of Obstetrics and Gynaecology, Tehran University of Medical Sciences, Tehran, Iran. 7Department of Obstetrics and Gynaecology, Tehran University of Medical Sciences, Tehran, Iran.8 Department of Obstetrics and Gynaecology, Tehran University of Medical Sciences, Tehran, Iran.
CORRESPONDING AUTHOR
Shideh Ariana,
Email : 10.14260/jemds/2019/773
ABSTRACT
Corresponding Author:
Shideh Ariana,
Tehran University of Medical Sciences,
Tehran, Iran.
E-mail: shideh.ryn23@yahoo.com
ABSTRACT
BACKGROUND
The physiology of postpartum period is still unknown. The aim of performing this study was evaluation of vascularity and colour Doppler blood flow in uterine myometrium after delivery.
METHODS
This cross-sectional study was conducted on 153 women undergoing caesarean section or vaginal delivery who were referred to the Shariati Hospital (Tehran-Iran) in 2018. All women underwent a transabdominal ultrasound examination the following day and one week after parturition. Six weeks later, the patients underwent transvaginal ultrasound. Enhanced myometrial vascularity is seen in ultrasound as a tubular echolucent view in the inner, middle, and outer region of the myometrium. Peak Systolic Velocity (PSV), Resistance Index (RI), and Pulsatility Index (PI) were calculated for hypervascular myometrial regions by Doppler. Endometrial thickness was measured, and the uterus was checked for presence or absence of pregnancy residue.
RESULTS
Mean age of participations was 30.43± 5.63 years. Nearly 80% of them had no history of abortion and delivery type in 110 (71%) was caesarean. In 105 (67.7%) cases, placental location was anterior. Uterine vascularity one day, one week and six weeks after delivery was significantly higher in women with placenta remnants (p<0.05). Means value for RI one and six weeks after delivery in women with posterior placenta location was significantly higher than other groups (p<0.05)
CONCLUSIONS
Our findings showed that placental remnants and endometrial thickness one day after delivery were in relation with uterine vascularity one day, one week and six weeks after delivery. In the present study, women with posterior placental location had higher resistance index than other groups
KEY WORDS
Vascularity, Doppler, Uterine Myometrium
BACKGROUND
The uterus weight during postpartum period is about one Kg which is affected by a physiological involution and change to condition of before of pregnancy.(1) The physiology of postpartum period is still unknown. Some of studies focus explain the changes in the size, shape, position, and the tissue of the uterus. The most of studies showed period of normal involution of 6 weeks after normal or pathological delivery in different parities.(2) The process of uterine involution is one of the main functions in the postpartum period that affected in pathological status including uterine infection and haemorrhage.(1) A few studies determine Doppler evaluations of uterine arteries during the normal involution period and it is very limit.(3,4) The vascular changes of continues in the myometrium for long during have been showed in gestational trophoblastic disease.(5) Doppler ultrasound has been applied to measure flow resistance indices of the uterine arteries during normal and pathological pregnancies and during labour.(6)
Patterns of abnormal uterine vascular in colour Doppler examination without evidence of placenta remains have been reported after women pregnancy.(7) Bosch et al. in 2002 reported that the uterine ultrasound and colour Doppler features after pregnancy can be valuable for the management of abnormal haemorrhage in the postpartum period.(8) Some studies showed that pulsatility indices (PI) decreased in the second trimester and remained low until the fourth week after delivery.(9) Also, resistance index (RI) of the uterine arteries from the first day postpartum continually increased, and in 4-6 weeks after delivery reached to non-pregnant values.(10)
Due to limited study in this field, the aim of performing of the current study was evaluation of vascularity and colour Doppler blood flow in uterine myometrium after delivery in Tehran, Iran.
METHODS
Study Design
This cross-sectional study was conducted on 153 women undergoing caesarean section or vaginal delivery who were referred to the Shariati hospital (Tehran-Iran) between Aprils to July 2018.
Eligibility Criteria
Diabetes or hypertensive patients or women with multiple pregnancy or cardiovascular complications or renal failure and mothers with IUGR born child were excluded from study. Pregnant women had given birth at between the 37th and 42th gestational week who were willing to participate to the study were considered as inclusion criteria. All included patients gave written consent and accepted to participate in study.
Procedure
All women underwent a transabdominal ultrasound examination the following day and one week after parturition using a Philips affinity 70 ultrasound device with convex c5-1 MHz probe, including colour Doppler imaging. Six weeks
later, the patients underwent transvaginal ultrasound with the C9-4 MH probe. Enhanced myometrial vascularity is seen in ultrasound as a tubular echolucent view in the inner, middle, and outer region of the myometrium. Peak systolic velocity (PSV), Resistance index (RI), and Pulsatility index (PI) were calculated for hypervascular myometrial regions by Doppler. Endometrial thickness was measured, and the uterus was checked for presence or absence of pregnancy residue. Demographic and medical history of patients including age, gravidity, parity, gestational age, fetal weight, placental location, status of use of uterotonic drugs, lactation, hemoglobin level, and pre- and postpartum bleeding were compared.
Data Analysis
Qualitative data were presented with frequency and percentage and quantitative variables were presented with mean+SD. Categorical variables were compared using chi-square test and continuous variables were compared using student t. test and one-way ANOVA. All the analyses were done using SPSS (Version 23) (SPSS Inc., Illinois, USA). P value less than 0.05 was considered as significant.
Ethical Considerations
Ethical approval for the study was obtained from the institutional review board of Tehran University of Medical Sciences according to Helsinki declaration. (Ethic code: IR.TUMS.MEDICINE.REC.1397.816).
RESULTS
A total of 153 women entered the study. The patients’ characteristics are summarized in table 1 for continues and in table 2 for categorical variables. Mean age was 30.43± 5.63 year and 60% of them were in 25-35 years age group. 38.7% were overweight and mean BMI was 28.31±4.62 Kg/m2. PSV was decreasing (34.06±14.04 in one day after delivery to 15.53±5.66 for 6 weeks after delivery. In return PI and RI were increasing. 78.8% had no history of abortion and delivery type in 110 (71%) was caesarean. The proportion of bleeding during 24 hours after delivery and bleeding after 24 hours of delivery was 11.6% and 2.6%, respectively. In 105 (67.7%) placental location was anterior.
|
Std. Deviation |
Mean |
Variable |
|
5.63 |
30.43 |
Age (Year) |
|
13.05 |
74.33 |
Weight (Kg) |
|
5.51 |
162.00 |
Height (cm) |
|
4.62 |
28.31 |
BMI |
|
400.50 |
3197.92 |
Birth weight (gr) |
|
1.04 |
12.68 |
Hb level one day before delivery |
|
1.22 |
11.48 |
Hb level one day after delivery |
|
3.04 |
11.70 |
Hb level 6 week after delivery |
|
14.04 |
34.06 |
PSV one day after delivery |
|
10.15 |
24.80 |
PSV one week after delivery |
|
5.66 |
15.53 |
PSV 6 week after delivery |
|
0.45 |
0.74 |
PI one day after delivery |
|
0.86 |
0.85 |
PI one week after delivery |
|
0.52 |
1.07 |
PI 6 week after delivery |
|
0.16 |
0.47 |
RI one day after delivery |
|
0.16 |
0.49 |
RI one week after delivery |
|
0.20 |
0.57 |
RI 6 week after delivery |
|
10.37 |
17.64 |
Days with bleeding |
|
Table 1. Women’s Characteristics (Mean Values ± Standard Deviation) |
||
|
PSV: Peak systolic velocity, RI: Resistance index, PI: Pulsatility index |
||
|
Variable |
Frequency |
Percent |
|
|
Age (Year) |
<25 year |
25 |
16.1 |
|
25-35 year |
93 |
60.0 |
|
|
>35 year |
37 |
23.9 |
|
|
BMI Category |
Normal |
40 |
25.8 |
|
Overweight |
60 |
38.7 |
|
|
Obese |
53 |
34.2 |
|
|
Gravidity |
1 |
40 |
25.8 |
|
2 |
54 |
34.8 |
|
|
3 |
28 |
18.1 |
|
|
≥4 |
33 |
21.2 |
|
|
Abortion |
0 |
116 |
74.8 |
|
1 |
26 |
16.8 |
|
|
2 |
11 |
7.1 |
|
|
3 |
2 |
1.3 |
|
|
Delivery type |
NVD |
45 |
29.0 |
|
Caesarean |
110 |
71.0 |
|
|
Bleeding during 24 hours after delivery |
Yes |
18 |
11.6 |
|
No |
137 |
88.4 |
|
|
Bleeding after 24 hours of delivery |
Yes |
4 |
2.6 |
|
No |
151 |
97.4 |
|
|
Placental location |
Anterior |
76 |
49.0 |
|
Posterior |
68 |
43.9 |
|
|
Fundal |
11 |
7.1 |
|
|
Vascularity location |
Anterior |
105 |
67.7 |
|
Posterior |
40 |
25.8 |
|
|
Fundal |
10 |
6.5 |
|
|
Vascularity one day after delivery |
Yes |
80 |
51.6 |
|
No |
75 |
48.4 |
|
|
Vascularity one week after delivery |
Yes |
68 |
43.9 |
|
No |
19 |
12.3 |
|
|
Vascularity 6 week after delivery |
Yes |
4 |
2.6 |
|
No |
41 |
26.5 |
|
|
Table 2. Women’s Characteristics (Frequency (%) |
|||
|
Variable |
Placental Remnants |
p |
||
|
Yes |
No |
|||
|
Uterine vascularity one day after delivery |
Yes |
15(78.9) |
4(21.1) |
0.01 |
|
No |
65(47.8) |
71(52.2) |
||
|
Uterine vascularity one week after delivery |
Yes |
6(54.55) |
5(45.45) |
0.005 |
|
No |
13(17.11) |
63(82.89) |
||
|
Uterine vascularity six week after delivery |
Yes |
2(25) |
6(75) |
0.077 |
|
No |
2(5.41) |
35(94.59) |
||
|
Delivery type |
NVD |
13(28.9) |
32(71.1) |
<0.001 |
|
Caesarean |
6(5.5) |
104(94.5) |
||
|
Induction |
No |
11(10.19) |
97(89.81) |
0.28 |
|
EASI one way |
0 |
1(100) |
||
|
One-way misoprostol |
2(33.33) |
4(66.67) |
||
|
One-way oxytocin |
5(19.23) |
21(80.77) |
||
|
More than one way |
1(7.69) |
12(92.31) |
||
|
Table 3. Relation between Placental Remnants with Uterine Vascularity Status, Delivery Type and Induction Type |
||||
|
NVD: Natural vaginal delivery. EASI: extra amniotic saline infusion |
||||
|
Variable |
Endometrial Thickness One Day after Delivery |
p |
||
|
<8 mm |
>8 mm |
|||
|
Uterine vascularity one day after delivery* |
Yes |
45(45.92) |
35(62.5) |
0.048 |
|
No |
53(54.08) |
21(37.5) |
||
|
Bleeding during 24 hours after delivery |
Yes |
10(55.56) |
8(44.44) |
0.41 |
|
No |
89(65.44) |
47(34.56) |
||
|
Bleeding after 24 hours of delivery |
Yes |
3(75) |
1(25) |
0.89 |
|
No |
96(64) |
54(36) |
||
|
Table 4. Relation between Endometrial Thickness with Uterine Vascularity Status and Bleeding after Delivery |
||||
|
*Percentages are presented by column |
||||
|
Variable |
Delivery type |
p |
Placental remnants |
p |
||
|
NVD |
Caesarean |
Yes |
No |
|||
|
PSV one day after delivery |
39.4±14.18 |
31.87±13.45 |
0.23 |
39.67±14.24 |
33.27±13.89 |
0.87 |
|
PSV one week after delivery |
27.45±8.27 |
23.95±10.59 |
0.42 |
30.77±13.4 |
23.93±9.39 |
0.04 |
|
PSV 6 week after delivery |
16.31±6.6 |
15.22±5.32 |
0.57 |
15.9±5.97 |
15.45±5.67 |
0.91 |
|
PI one day after delivery |
0.75±0.38 |
0.74±0.48 |
0.23 |
0.85±0.53 |
0.73±0.44 |
0.45 |
|
PI one week after delivery |
0.79±0.43 |
0.87±0.96 |
0.55 |
0.82±0.46 |
0.86±0.91 |
0.78 |
|
PI 6 week after delivery |
1.05±0.39 |
1.08±0.57 |
0.03 |
0.96±0.52 |
1.09±0.53 |
0.59 |
|
RI one day after delivery |
0.48±0.15 |
0.47±0.17 |
0.26 |
0.5±0.17 |
0.47±0.16 |
0.8 |
|
RI one week after delivery |
0.5±0.15 |
0.48±0.16 |
0.68 |
0.47±011 |
0.49±0.16 |
0.4 |
|
RI 6 week after delivery |
0.59±0.13 |
0.57±0.22 |
0.012 |
0.54±0.19 |
0.58±0.2 |
0.64 |
|
Table 5. PSV, PI and RI Mean Values in 1, 7 and 42 Days after Delivery by Delivery Type and Placental Remnants |
||||||
|
Variable |
Placental Location |
p |
||
|
Anterior |
Posterior |
Fundal |
||
|
PSV one day after delivery |
32.83±14.45 |
34.93±14.04 |
37.2±11.1 |
0.5 |
|
PSV one week after delivery |
24.64±11.08 |
24.94±9.05 |
25.42±8.7 |
0.98 |
|
PSV 6 week after delivery |
14.69±4.2 |
16.5±7.2 |
17.07±7.66 |
0.52 |
|
PI one day after delivery |
0.78±0.45 |
0.71±0.47 |
0.74±0.34 |
0.68 |
|
PI one week after delivery |
0.75±0.44 |
1.07±1.32 |
0.57±0.15 |
0.19 |
|
PI 6 week after delivery |
0.96±0.55 |
1.27±0.45 |
0.96±0.44 |
0.16 |
|
RI one day after delivery |
0.48±0.17 |
0.45±0.16 |
0.48±0.14 |
0.5 |
|
RI one week after delivery |
0.46±0.12 |
0.55±0.20 |
0.42±0.08 |
0.023 |
|
RI 6 week after delivery |
0.55±0.2 |
0.66±0.15 |
0.4±0.22 |
0.034 |
|
Table 6. PSV, PI and RI Mean Values in 1, 7 and 42 Days after Delivery by Placental Location |
||||
In table 3 Relation between Placental remnants with uterine vascularity status, delivery type and induction type is presented. Uterine vascularity one day, one week and six weeks after delivery was significantly higher in women with placental remnants (p<0.05). Women with NVD delivery had significantly higher rate of Placental remnants (25% vs. 5.41%, p<0.001).
Table 4 shows that there is a significant relation between endometrial thickness one day after delivery with uterine vascularity, so that in women with endometrial thickness one day after delivery more than 8 mm the percentage of uterine vascularity were higher (p=0.048), but in these women the rate of bleeding after 24 hour of delivery was not significant (p=0.89).
PSV, PI and RI mean values in 1, 7 and 42 days after delivery by delivery type and placental remnants are shown in table 5. As shown PSV one week after delivery was significantly higher in patients with placental remnants (30.77±13.4 vs. 23.93±9.39, p=0.04). PI 6 week after delivery was significantly higher in patients with caesarean delivery (1.08±0.57 vs. 1.05±0.39, p=0.03), while RI 6 week after delivery was significantly higher in patients with NVD delivery (0.59±0.13 VS. 0.57±0.22, p=0.012). As shown in table 6 means value for RI one and six weeks after delivery in women with posterior placental location was significantly higher than other groups (p<0.05).
DISCUSSION
Our findings showed that uterine vascularity one day, one week and six weeks after delivery was significantly higher in women with placental remnants. Also, there is a significant relation between endometrial thickness one day after delivery with uterine vascularity. In present study, the mean of RI one and six weeks after delivery in women with posterior placental location was significantly higher than other groups. Areas of enhanced myometrial vascularity are seen in early postpartum. These areas located at the former placental site and within 6 weeks after delivery, usually are disappear.
Van den Bosch et al. reported that Enhanced myometrial vascularity was associated with retained placental tissue.(8) Therefore, this is in line with our findings. The retained placental tissue was more frequently seen after instrumental removal of the placental, in patients who needed blood transfusion in the early postpartum, and in multigravidas.(8) Other study by Van Schoubroeck in 2003 reported that Areas of enhanced myometrium vascularity were visualized in 50.5% and 3.9% of patients on the third day and the sixth week.(11)
Colour Doppler examination diagnosed areas of enhanced vascularity in 8.3% of women. The most of patients were focal areas of one or more vessels. Abnormal vascularity extended over a large area of the myometrium and placental remnants were diagnosed in 2.6% and 6.75% of patients, respectively. The miscarriage in first or second trimester, instrumental delivery of the placental, presence of placental remnants and a shorter interval between last pregnancy and the examination were significance factors in predicting enhanced vascularity.(8)
Our study showed that the mean of RI one and six weeks after delivery in women with posterior placental location was significantly higher than other groups. However, RI in the uterine artery in the normal postpartum can help us to better understand normal physiology, and to better interpret pathophysiology of the postpartum.
Our study had some limitations. (a) The design of this study was cross-sectional; we proposed this study was performed in a design of large cohort for evaluating of long-time complication. (b) Women should have performed uterine perfusion ultrasound at different times in postpartum, this could limit the frequency of patient referrals. Therefore, we decreased this limitation by giving training to patients and free visits for performing of ultrasound.
CONCLUSION
Uterine vascularity one day, one week and six weeks after delivery was significantly higher in women with placental remnants. Also, there is a significant relation between endometrial thickness one day after delivery with uterine vascularity. In the present study, the mean of RI one and six weeks after delivery in women with posterior placental location was significantly higher than in other groups.
ACKNOWLEDGEMENT
This study was supported by Tehran University of Medical Sciences (TUMS). Authors thank the participants as well as staff of Shariati Hospitals.