POSTPARTUM

INVOLUTION
Nur Fatharani – Tutor 17
Bahasan
01 PUERPERIUM

02 UTERUS CHANGE

03 USG FINDINGS

CLINICAL ASPECT
04 • After Pains
• Lochia
UTERUS
1. The caliber gradually diminishes to approximately that of the
prepregnant state

2. Larger blood vessels become obliterated by hyaline changes

o They are gradually resorbed and replaced by smaller ones
o Minor vestiges of the larger vessels, however, may persist for years

3. During labor :
o the margin of the dilated cervix, which corresponds to the external os,
may be lacerated
o The cervical opening contracts slowly, and for a few days immediately
after labor, it readily admits two fingers

4. By the end of the first week :

o cervical opening narrows
o cervix thickens
o endocervical canal re-forms
5. The external os does not completely resume its pregravid
appearance. It remains somewhat wider, and typically,
ectocervical depressions at the site of lacerations become
permanent
6. Cervical epithelium also undergoes considerable remodeling. This
actually may be salutary because almost half of women have
regression of high-grade dysplasia following delivery
7. After delivery, the fundus of the contracted uterus lies slightly
below the umbilicus. It consists mostly of myometrium covered by
serosa and internally lined by decidua
8. The markedly attenuated lower uterine segment contracts and
retracts, but not as forcefully as the uterine corpus

9. During the next few weeks, the lower segment is converted from a
clearly distinct substructure large enough to accommodate the
fetal head to a barely discernible uterine isthmus located between
the corpus and internal cervical os

10. Immediately postpartum :

o the anterior and posterior walls, which lie in close apposition,
are each 4 - 5 cm thick
o the uterus weighs approximately 1000 g
11. Myometrial involution is a truly remarkable feat of destruction or
deconstruction that begins as soon as 2 days after delivery
12. The total number of myocytes does not decrease appreciably-
rather, their size decreases markedly

13. As emphasized by Hytten (1995), the quality of studies that

describe the degree of decreasing uterine weight postpartum are
poor. Best estimates show that the uterus weighs approximately :
o 1 week postpartum : 500 g
o 2 week pp : 300 g
o 4 weeks pp : involution is complete, 100 g

14. After each successive delivery, the uterus is usually slightly larger
than before the most recent pregnancy.
Sonographic
Findings
• Uterine involution and rapid dissipation of size progresses in the first
week (Fig. 36-2)
• Sonographically, the uterus and endometrium return to pregravid size
by 8 weeks postpartum
• In a study of 42 normal puerperas, Tekay and Jouppila (1993)
identified fluid in the endometrial cavity in 78% of women at 2 weeks,
52% at 3 weeks, 30% at 4 weeks, and 10% at 5 weeks
• Belachew and coworkers (2012) used three-dimensional sonography
and visualized intracavitary tissue matter in a third on day 1, in 95%
on day 7, in 87% on day 14, and in 28% on day 28. By day 56, the small
cavity was empty
• Sohn and associates (1998) described Doppler ultrasound results
showing continuously increasing uterine artery vascular resistance
during the first 5 days postpartum
 Decidua &
Endometrial
Regeneration
1. Because separation of the placenta and membranes involves the
spongy layer, the decidua basalis is not sloughed

2. The in situ decidua varies markedly in thickness, it has an

irregular jagged border, and it is infiltrated with blood,
especially at the placental site

3. Within 2 or 3 days after delivery, the remaining decidua

becomes differentiated into two layers
• The superficial layer becomes necrotic and is sloughed in the
lochia
• The basal layer adjacent to the myometrium remains intact
and is the source of new endometrium
4. Endometrial regeneration is rapid, except at the placental
site.

5. Within a week or so, the free surface becomes covered by

epithelium, and Sharman (1953) identified fully restored
endometrium in all biopsy specimens obtained from the
16th day onward

6. Histological endometritis is part of the normal reparative

process.
After Pains
• In primiparas , the uterus tends to remain tonically contracted following
delivery
• In multiparas, it often contracts vigorously at intervals and gives rise to
afterpains, which are similar to but milder than labor contractions
• These are more pronounced as parity increases and worsen when the
newborn suckles, likely because of oxytocin release (Holdcroft, 2003)
• Usually, afterpains decrease in intensity and become mild by the third day
• There may be unusually severe and persistent afterpains in women with
postpartum uterine infections
Lochia
• Early in the puerperium, sloughing of decidual tissue results in a
vaginal discharge of variable quantity  the discharge is termed
lochia
• Lochia contains erythrocytes, shredded decidua, epithelial cells, and
bacteria
• Lochia rubra  For the first few days after delivery, there is blood
sufficient to color it red
• Lochia serosa  After 3 or 4 days, lochia becomes progressively pale in
color
• Lochia alba  After approximately the 10th day, because of an admixture
of leukocytes and reduced fluid content, lochia assumes a white or yellow-
white color
• The average duration of lochial discharge ranges from 24 to 36 days
 Sumber
Williams Obstetrics Ed25
hal. 667-669
Thank you