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  1. Endomyometritis: puerperial infection involving the endometrium and myometrium, usually involving multiple bacterial organisms including gram-negative enteric organisms and anaerobic bacteria. The patient usually manifests fever, uterine tenderness, and has had a cesarean.

  2. Hepatic subcapsular hematoma: bleeding into the liver parenchyma leading to collection of blood distending the liver capsule. This condition, a complication of preeclampsia, puts the patient at risk for hematoma rupture and substantial bleeding.

  3. Ovarian vein thrombosis: a condition where pelvic veins involving the gonadal vein have a thrombus (clot), usually infected. The patient usually presents with fever, lateral abdominal pain, and may have a palpable pelvic mass.

  4. Placenta accreta: abnormal adherence of the placenta to the uterine lining, usually due to abnormal placental penetration into the decidual layer of the endometrium. This condition is increased by the number of prior cesareans.

  5. Postpartum hemorrhage: bleeding after delivery traditionally exceeding 500 mL on a vaginal delivery, and 1000 mL on a cesarean delivery. Early postpartum hemorrhage is less than 24 hours after the delivery, and late postpartum hemorrhage means exceeding 24 hours after delivery.

  6. Puerperium: the time after delivery until 6 weeks postpartum.

  7. Retained placenta: substantial amount of chorionic villi and products of conception retained in the uterus, typically causing bleeding or infection.


During pregnancy, numerous dramatic physiologic changes take place, and then after delivery, whether by the vaginal or cesarean route, these changes resolve even more rapidly. This process of resolution occurs during the puerperium, which is the 6 weeks following delivery. In 1972, Robinson first described using diagnostic ultrasound to image the postpartum pelvic organs.1 Since that time, ultrasound has continued to play an important role in the diagnosis of postpartum anatomical structures, particularly in conditions of infection, hemorrhage, or suspected retained placenta; processes that require imaging include assessment of women with persistent postpartum endomyometritis, pelvic abscesses, retained placental fragments, and hematomas of the uterus, bladder, peritoneal flap, or abdominal wall. Such complications can involve up to 5% to 10% of postpartum women.2


This chapter reviews normal and pathologic sonographic findings during the puerperium, with the major emphasis on the pelvic organs, although the urinary tract, hepatobiliary tract, and vasculature are also covered. The normal anatomy, including variations of normal, and the changes associated with pregnancy and further alterations by the various disorders are reviewed.




Normal Anatomy

The Uterus

In the nonpregnant state, the uterus occupies a midline position that measures approximately 8 cm in length. Uterine size may be affected by parity, and pathologic conditions such as leiomyomata or adenomyosis.3 The uterus grows from a pregravid weight of 140 g to a peak of 1 kg at term; the uterine blood flow increases from 50 mL/min to 500 mL/min at term.2 The uterus shrinks remarkably during the puerperium, without cellular destruction; instead, there is a reduction in cell size ...

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