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Re: Postpartum uterusFrom: =?utf-8?q?Dr. Bülent Potur?= (bpotur@yahoo.com)Fri Jul 27 16:11:12 2007
Sir, I can not compare apples and oranges. Of course one may see untractable bleeding in post partum patients due to many conditions and may have to do hysterectomy. This is something different. What has been the issue in this thread is the state of hypoestrogenism in women with well established lactation such as who breast feed only. Bulent Potur Here is some literature: Elevated prolactin level during lactation is considered as a factor that increases the risk of developing atrophic vaginitis : http://www.aafp.org/afp/20000515/3090.html another Am J Obstet Gynecol. 1991 Oct;165(4 Pt 2):1249-54. Postpartum vaginal atrophy. Wisniewski PM, Wilkinson EJ. JAMA. 1983 Jun 17;249(23):3152. Greater IUD perforation risk, lactation linked. Merz B. Obstet Gynecol. 1983 Jan;61(1):31-6. Risk of uterine perforation among users of intrauterine devices. Heartwell SF, Schlesselman S. " Most important, women who were lactating at the time of IUD insertion were 10 times as likely to have had a uterine perforation as women with at least 1 live birth but who were not lactating at the time of insertion. An incarcerated IUD resulting in a difficult removal was 2.3 times as likely among women lactating at the time of insertion compared to women not lactating at the time of insertion. The likelihood of both uterine perforation and uterine incarceration were unchanged regardless of the type of IUD used." Eur J Obstet Gynecol Reprod Biol. 1984 Jun;17(4):257-61.Uterine perforation by copper intrauterine device.Heinonen PK, Merikari M, Paavonen J. " Sixteen cases with uterine perforation by a copper intrauterine device (IUD) are presented. In 13 cases the IUD had been inserted within 5 months following delivery, and in 6 cases the insertion had been painful. Missing string was the first sign in most cases." Adv Contracept. 1990 Mar;6(1):57-61 Perforation of the uterus following IUD insertion in the puerperium. Kiilholma P, Mäkinen J, Mäenpää J. Department of Gynecology and Obstetrics, Turku University Central Hospital, Finland. "Perforation of the uterus by an IUD is very rare. However, during the puerperium when the uterus is small and the uterine wall is thin the risk of perforation increases. We present three patients treated within a rather short period of time at our institution for perforation of the uterus caused by IUD insertion 3-4 months after delivery." Ultrasound Obstet Gynecol. 2004 Apr;23(4):378-81. Prospective evaluation of blood flow in the myometrium and uterine arteries in the puerperium. Van Schoubroeck D, Van den Bosch T, Scharpe K, Lu C, Van Huffel S, Timmerman D. Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Belgium. VanSchoubroeck@uz.kuleuven.ac.be "OBJECTIVE: Heavy bleeding in the late postpartum has, in some cases, been attributed to subinvolution of the placental bed and enhanced myometrial vascularity (EMV) as seen on color Doppler imaging. The aim of this study was to investigate the incidence and spontaneous evolution of areas of enhanced vascularization over the whole thickness of the myometrium in asymptomatic women after uncomplicated term pregnancy. METHODS: This was a prospective descriptive study involving 93 consecutive women who were examined on day 3 (mean 2.6 +/- 1.5) and at 6 weeks (mean 6.5 +/- 1.3) after delivery following an uncomplicated term pregnancy. EMV was defined as the presence of marked flow over the full thickness of the myometrium reaching the uterine cavity. Doppler flow examination within the area of EMV and of both uterine arteries was performed. RESULTS: The mean patient age was 29.1 years and average parity was 1.7. The mean gestational age at delivery was 39.1 weeks. Areas of EMV were visualized in 50.5% of patients on day 3 vs. 3.9% at 6 weeks. None of the patients required therapy for bleeding problems. The mean pulsatility index and peak systolic velocity in the area of EMV on day 3 were 0.45 +/- 0.30 and 0.37 +/- 0.20 m/s, respectively. A consistent increase in vascular resistance and decrease in blood flow velocity was observed in both uterine arteries between day 3 and week 6. CONCLUSIONS: Most areas of EMV reflect intermediate stages in the involution of the placental bed and do not cause abnormal postpartum bleeding. EVM is common in the puerperium, disappears spontaneously in the vast majority of cases, and does not warrant treatment if asymptomatic. Further research is needed to predict the rare cases in which subinvolution of the placental bed leads to heavy bleeding in the late postpartum. Copyright 2004 ISUOG." Raymond Stephen <stephen.raymond@dhhs.tas.gov.au> wrote: You never know, you might have to one day. It might be the condition that leads you to do a hysterectomy at 6 weeks that is responsible for the hyper vascularity. Nevertheless, the relative hypo-oestrogenism of lactation is most definitely not reflected in any suggestion of avascularity or even hypo-vascularity of the uterus. Involution is not complete until a minimum of 6 weeks and until it is the myometrium is soft and spongy - ideal for an IUCD to perforate. Steve -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Dr. Bülent Potur Sent: Thursday, 26 July 2007 10:38 PM Sir, I have hot been there. But I can tell you anyhow that I wouldn't do a hysterectomy on a 6 weeks postpartum lactating woman with a completely involutioned healthy uterus. Regards, Bulent Potur
At Wed, 25 Jul 2007, R. Daniel Braun wrote:
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