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Archives of gynecology and obstetrics

Application of uterotonics on the basis of regular ultrasonic evaluation of the uterus prevents unnecessary surgical intervention in the postpartum period.


PMID 19760186

Abstract

Ultrasonographic evaluation of the postpartum uterus to prevent retained placental tissue complications is still a matter of debate, and it is difficult to interpret its necessity on the basis of previous studies. We hypothesized that the application of uterotonics on the basis of regular postpartum ultrasound scanning of the uterus may reduce the number of unnecessary curettages in a large unselected population. This was a cross-sectional observational study conducted among mothers (n = 6,028) delivering at two different (secondary and tertiary) hospitals to analyze the benefit of postpartum uterine ultrasound for clinical implications. Women delivering at the secondary care unit (n = 1,915) had no regular postpartum ultrasound scans in comparison to those delivering at the tertiary unit (n = 4,113). On regular ultrasound scans, morphological findings in the uterine cavity were recorded. Upon the presence of an intrauterine hyperechogenic mass larger than 2 cm in diameter, mothers received a single dose of uterotonics (methylergometrin 0.2 mg or oxytocin 5 IU) intramuscularly and control sonography after 24 h. In case of intrauterine mass persistence and serious postpartum hemorrhage women underwent a surgical intervention. The management was similar at the secondary unit, but ultrasound scans were provided only when there was a clinical finding. All patients were followed-up 6 weeks after labor. Women delivering at the secondary institution experienced a higher incidence of puerperal surgical interventions (1.51 vs. 0.87%) and lower agreement between sonography and histological findings (72.4 vs. 86.1%) compared with women delivering at the tertiary care unit, respectively (P < 0.05), where the general incidence of interventions was 1.10% after spontaneous and 0.19% after cesarean deliveries. In addition, trained sonographers reached only 13.9% false-positive ultrasound scans. Time-dependent regression analysis of uterine morphological involution variables showed a significant association between uterine length, width, uterine cavity and cervical channel mass, P < 0.0001, P < 0.01, P < 0.05, P < 0.05, respectively, and insignificant association between uterine cavity volume with an increased time period postpartum. In this study, routine ultrasound evaluation of the uterus in the postpartum period with regular application of uterotonics decreased the rate of surgical interventions. We strongly advise the introduction of postpartum uterine scanning into obstetrical practice, most suitably provided around day 3 after delivery.