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2019 Month : December Volume : 8 Issue : 48 Page : 3579-3582

Evaluation 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,
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

How to cite this article

Ariana S, Marsoosi V, Jamal A, et al. Evaluation of vascularity and colour doppler blood flow in uterine myometrium after delivery. J. Evolution Med. Dent. Sci. 2019;8(48):3579-3582, DOI: 10.14260/jemds/2019/773

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.

 

 

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