Ultrasound Obstet Gynecol 2001; 18: 491 498

Ultrasonic evaluation of the uterus and uterine cavity after

Blackwell Science Ltd

normal, vaginal delivery

A. MULIC-LUTVICA, M. BEKURETSION, O. BAKOS and O. AXELSSON
Department of Womens and Childrens Health, Uppsala University, Uppsala, Sweden

K E Y WOR D S: Human pregnancy, Normal puerperium, Ultrasound, Uterus

puerperium and in the whole uterine cavity in the middle part

ABSTRACT
Objective To describe uterine and uterine cavity changes
throughout the puerperium, as revealed by ultrasound.
Methods This was a prospective, longitudinal study in which
42 women with uncomplicated vaginal term deliveries were
examined serially by ultrasound on postpartum days 1, 3, 7,
14, 28 and 56. The first four examinations were performed
transabdominally and the last two transvaginally. The
involution process of the uterus was assessed by measuring
the anteroposterior diameter of the uterus and uterine cavity.
Morphological findings were recorded. The influence on the
involution process of parity, breast-feeding, maternal smoking
and infants birth weight were also evaluated.
Results The maximum anteroposterior diameter of the uterus
diminished substantially and progressively from 92.0 mm on
day 1 postpartum to 38.9 mm on day 56. The maximum
anteroposterior diameter of the uterine cavity diminished
from 15.8 mm on day 1 to 4.0 mm on day 56. However, the
anteroposterior diameter of the uterine cavity, 5 cm from the
fundus, typically increased on days 7 and 14 postpartum. The
position of the uterus and the shape and the appearance of the
cavity change in a unique way during the normal puerperium.
The uterus was most often retroverted and empty in the early
puerperium. Fluid and debris in the whole cavity were seen
in the middle part of the puerperium. In late puerperium the
cavity was empty and appeared as a thin white line.
Endometrial gas was occasionally visualized. No correlation
was found between the involution of the uterus and parity,
breast-feeding and the infants birth weight.
Conclusion Transabdominal sonography is suitable for
examination of the uterus during the first 14 days postpartum
but from day 28 the transvaginal route is preferable. The
uterine body and position, as well as the cavity, are easy to
examine by ultrasound. Accumulation of fluid and debris in
the uterine cavity is a common and insignificant finding of the
involuting uterus. It is located in the cervical area in the early
of the puerperium. Findings from uncomplicated vaginal
deliveries are needed as a reference when the diagnostic efficacy
of ultrasound for pathological conditions is to be tested.
INTRODUCTION
The puerperium is defined as the period of 68 weeks after
delivery during which the uterus, which weighs more than
1 kg soon after delivery, undergoes physiological involution
and returns to the non-pregnant state. Our previous knowledge
about the puerperal uterus is mainly based on histological
studies obtained from postmortem examination when maternal
death during the puerperium was commonplace1. The involu-
tion process of the uterus as a main characteristic of the puer-
perium was previously assessed by palpation of fundal height,
which can be difficult in obese women and in women with
uterine myoma2.
Although the uterus was one of the first organs to be
examined by ultrasound when ultrasound was introduced
into clinical practice by Donald et al.3 only a few ultrasound
studies have involved investigations during the puerperium49.
In the majority of previously published studies, old com-
pound scanners with poor image resolution were used. The
actual timing of measurements is rarely specified. More-
over, the examinations were most often restricted to the
early puerperium712 and only one study was longitudinally
designed13. There is disagreement concerning the influence on
the involution process of parity79,1416 breast-feeding8,9,11,14,16
or the infants birth weight8,11,16. There are also confusing
data about the presence of gas10,12,17 fluid or echogenic masses
in the cavity during the normal puerperium.
A description of normal ultrasonic changes of the uterus in
the puerperium is a prerequisite for ultrasound diagnosis of
pathological conditions. It should be useful to know the normal
ultrasound appearance of the uterus throughout the entire
puerperal period in order to improve our ability to distinguish
puerperal pathology from normal conditions and thus avoid

Correspondence: Dr A. Mulic-Lutvica, Department of Obstetrics and Gynaecology, University Hospital, SE 751 85 Uppsala, Sweden
(e-mail: ajlana.mulic-lutvica@kk.uas.lul.se)
Received 1-8-00, Revised 18-6-01, Accepted 1-8-01

ORIGINAL PAPER 491

Ultrasound in puerperium Mulic-Lutvica et al.

unnecessary invasive procedures. Moreover, the knowledge
obtained through ultrasonic examinations can help us to better
understand the physiology of the puerperium.
Our aim was to describe the uterine and uterine cavity
changes after a vaginal, uncomplicated, term delivery and
uneventful puerperal course. A secondary aim was to see if
the uterine involution process was influenced by parity,
infant birth weight, breast-feeding or maternal smoking.
postpartum (Table 1). The maximum AP diameter of the
uterus decreased from 92.0 mm on day 1 to 38.9 mm on
day 56.
The mean AP diameter of the cavity 5 cm from the fundus
increased from 6.6 mm on day 1 to 9.2 mm on day 7. There-
after the diameter decreased continuously to 2.0 mm on day
56. The mean of the maximum AP diameter of the cavity
decreased from 15.8 mm on day 1 to 4.0 mm on day 56. The

MATERIAL AND METHODS

Sixty women were asked to participate in the study between
1996 and 1998. Seven did not wish to participate. Four
women took part only in the first ultrasound examination.
Seven women developed puerperal pathology. Thus, 42 women
remained in the study. Informed consent was obtained from
all women recruited into the study. All 42 women had
uncomplicated, singleton pregnancies with a term vaginal
delivery and an uneventful puerperal course. The study was
approved by the ethics committee of the medical faculty of
Uppsala University, Sweden.
The median age of the women was 28 (range, 1941)
years. Eighteen were primiparous and 24 were multiparous.
Twenty-two were breast-feeding their infants, whereas 20
used bottle-feeding. Five women were smokers and 37 were
non-smokers. The median birth weight of the infants was
3545 (range, 26404510) g.
All ultrasound examinations were performed with com-
mercially available real-time machines (Acuson 128, Mountain
View, CA, USA; Siemens sonoline SI-400, Erlangen, Germany;
Toshiba Sonolayer Capasee SSA, Tokyo, Japan) with a 3.5-MHz
transabdominal convex probe and a 5-MHz vaginal probe.
The ultrasound examinations were scheduled for days 1, 3, 7,
14, 28, and 56 after delivery. For the first four examinations a
transabdominal probe was used and for the last two a trans-
vaginal probe was used. The women had a moderately filled
urinary bladder when examined. Tender compression by the
probe was used and the measurements were made between
uterine contractions. The uterus was assessed in the longitudinal,
transverse and coronal sections (Figure 1). The coronal sec-
tion was analyzed in order to exclude uterine malformations.
In the longitudinal section the maximum anteroposterior (AP)
diameters of the uterus and uterine cavity, perpendicular to the
endometrium, were measured. The same measurements were
also made at a distance of 5 cm from the uterine fundus. The
form and position of the uterus were recorded, as were the pres-
ence of fluid, heterogeneous contents, or gas in the uterine cavity.
The quantitative variables were analyzed utilizing the JMP
from the SAS statistical package (SAS Institute Inc., Cary,
NC, USA, 1997. JMP Version 3.2). Comparisons between
groups were carried out using the t-test.

RESULTS
Table 1 summarizes the measurements of the uterus and
uterine cavity. Tables 2 and 3 summarize the qualitative
Figure 1 Transabdominal ultrasound scans of a normal puerperal
parameters of the uterus and uterine cavity. uterus on day 1: a longitudinal scan (a) (angulated form of the uterus was
The mean AP diameter of the uterus 5 cm from the fundus avoided by semireclining position of examined woman), a transverse
decreased from 83.5 mm on day 1 to 28.1 mm on day 56 scan (b) and a coronal scan (c).

492 Ultrasound in Obstetrics and Gynecology

Ultrasound in puerperium Mulic-Lutvica et al.

maximum diameter of the cavity was found in the lower uterine
segment on days 1 and 3. The maximum diameter on days 7,
14, 28 and 56 was found in the middle part of the uterine cavity.
Figure 2 shows graphs of individual data of the uterine and
cavity diameters.
During early puerperium the cavity was empty in 39 of 42
women on day 1 (92.9%) (Figure 3a) and in 35 of 42 women
on day 3 (83.3%) (Figure 3d). The cavity was seen as a con-
tinuous white line along the entire uterine cavity from the
internal cervical os to the top of the fundus. A thicker and
more heterogeneous pattern was seen in three of 42 women
(7.1%) on day 1 (Figure 3b). An empty cavity was found during
the middle part of the puerperium in four of 41 women on
day 7 (9.8%) and in 10 of 41 women on day 14 (24.4%).
Table 3 shows that the majority of women had some content
in the cavity on days 7 and 14, independently of the cavity status
on days 1 and 3. The content was either fluid or had a hetero-
geneous pattern with solid and fluid components filling the
whole cavity (Figure 4). During late puerperium an empty cavity
was found in 29 of 39 (74.4%) women on day 28 and in 39
of 41 (95.1%) women on day 56. The endometrium appeared
as a thin white line (Figure 5a and c). In 10 of 39 (26%)
women on day 28, a minimal amount of fluid or echogenic dots
separated this endometrial line (Figure 5b).
The cervical area was empty in nine of 42 women (21.4%)
on day 1. The majority of women, 33 of 42 (78.6%) had a
collection of fluid with mixed echo pattern in the cervical area
(Figure 3c). In 22 of 42 (52.3%) women this was expelled
and an empty cavity was seen on the following day. On day
7 the cavity contained fluid or there was debris in the whole
cavity including the cervical area in a majority of women and
in just nine of 41 (22%) women, the cervical area was empty.
An empty cervical area was seen on day 14 in 37 of 41 women
(90.2%), on day 28 in 31 of 39 (79.5%) women and on day
56 in 39 of 41 (95.1%) women.
A minor hyperechogenic focus in the cavity was seen in two
of 42 women (4.8%) on day 1. On day 3 it had disappeared.
On day 7 one of 41 women (2.4%) had a hyperechogenic
focus, which was observed on each of the following occasions.
On day 14 two of 41 women (4.9%) had scanty amounts of
particulate matter. In one case a reverberation artifact was
seen (Figure 4c) which disappeared by day 28.
The normal shape of the early puerperal uterus in the sagittal
plane was angulated and the position was retroverted in 40
of 42 women (95.2%) on day 1 and in 37 of 42 women
(88.1%) on day 3 (Table 2). On day 7 the shape and the position
of the uterus had changed. It was more oval and anteverted
in 30 of 41 (73.2%) women (Figure 4a). On day 14 the uterus
was anteverted in 39 of 41 (95.1%) women (Figure 4b). On
day 28 an anteverted position of the uterus was seen in 36 of
39 (92.3%) women (Figure 5a). On day 56 the involution
process was completed. The uterus had an anteverted posi-
tion in 36 of 41 (87.8%) women (Figure 5c).
A schematic summary of the uterine and uterine cavity
changes throughout the puerperium is shown in Figure 6.
No correlation was found between the different measure-
ments and parity, infants birth weight or breast-feeding.
Although the AP diameters of parous women were somewhat
larger than those of nulliparous women, the difference was
not statistically significant. Women who smoked had slightly

Table 1 Uterine and uterine cavity dimensions during a normal puerperium

Uterine AP diameters (mm) (Mean (SD, range)) Cavity AP diameters (mm) (Mean (SD, range))
Postpartum day 5 cm from fundus Maximum 5 cm from fundus Maximum

1 83.5 92.0 6.6 15.8

(10.6, 61.5 101) (9.4, 70109.3) (3.6, 0.916.1) (8.1, 3.545.2)
3 79.5 87.2 6.7 13.2
(9.4, 64.3 98) (9.4, 68.5109) (4.9, 1.833) (8.9, 2.536)
7 69.9 74.9 9, 2 15.2
(10.1, 47.2 93.7) (7.9, 58.394) (6.7, 0.937) (8.2, 3.244)
14 59.6 63.4 7.1 9.1
(7.5, 48 86) (7.4, 5086) (4.7, 0.718) (4.7, 2.522)
28 42.0 49.2 3.4 5.5
(8.4, 21.6 58) (5.7, 36.861) (2.3, 0.711) (2.8, 1.421)
56 28.1 38.9 2.0 4.0
(6.2, 18.2 41.7) (5.2, 29.450) (0.9, 0.96.0) (2.6, 110)

AP, anteroposterior.

Table 2 Qualitative findings in the uterus and uterine cavity during a normal puerperium

Postpartum day
Finding 1 3 7 14 28 56

Empty cavity (n (%)) 39 /42 (92.9) 35/42 (83.3) 4/41(9.8) 10/41 (24.4) 29/39 (74.4) 39/41 (95.1)
Empty cervical area (n (%)) 9 /42 (21.4) 22/42 (52.3) 9/41(22.0) 37/41 (90.2) 31/39 (79.5) 39/41 (95.1)
Gas/hyperechogenic foci (n (%)) 2 /42 (4.8) 0/42 (0) 1/41 (2.4) 2/41 (4.9) 2/39 (5.1) 1/41 (2.4)
Anteverted uterus (n (%)) 2 /42 (4.8) 5/42 (11.9) 30/41 (73.2) 39/41 (95.1) 36/39 (92.3) 36/41(87.8)
Missing (n) 0 0 1 1 3 1
Total (n) 42 42 41 41 39 41

Ultrasound in Obstetrics and Gynecology 493

Ultrasound in puerperium Mulic-Lutvica et al.

higher maximum AP diameters of the uterus (P = 0.0432).

However, only five women were smokers.

DISCUSSION
Since its introduction into obstetric practice3 ultrasound
has made non-invasive investigation of the uterus possible.
However, previously published studies involving sonographic
examination of the puerperal uterus are not unambigu-
ous411,1416. Most studies are cross-sectional and old compound
scanners were used49. The accurate timing of measurements
is not always specified. A recently published study by Sakki
and Kirkinen was restricted to the early puerperium12. In a
report by Tekay and Jouppila, attention was focused on
puerperal hemodynamic changes13. There are also conflict-
ing data about the best indicator of the involution process.
Length7,911,1316, width10,1416, AP diameter9,11,16 and area14

Table 3 Individual findings in the uterine cavity during a normal puerperium

Empty cavity (yes/no) on postpartum day

Case 1 3 7 14 28 56

1 y y n n y y
2 y y n n y y
3 y y n y y y
4 y n n n y y
5 y y y n n y
6 y y n n y y
7 y y n y y y
8 y y n n y n
9 y y n n n y
10 y y n n n y
11 y y y n n y
12 y y n n n y
13 y n n n y y
14 y y y y y n
15 y y n y y y
16 y y n n y y
17 y y n n n y
18 y n n n y y
19 y y n n y y
20 y y n n y y
21 y y y n y y
22 y y n n y y
23 y y n y y y
24 y y n n y y
25 y y n n y y
26 n n n n n y
27 y y n y y y
28 y y n n y y
29 y y n n n y
30 y y n n n y
31 y y n n y y
32 y y n n y y
33 n n n n n y
34 y y n y y y
35 y y n y y y
36 y y n n y y
37 y y n y y y
38 n n n y y
39 y n n y y
40 y y n n y
41 y y n n y
Figure 2 Individual uterine (a, b) and uterine cavity (c, d) measurements 42 y y n y
throughout the puerperium.

494 Ultrasound in Obstetrics and Gynecology

Ultrasound in puerperium
of the uterus have been used, as well as thickness of the uterine
wall10,15. As regards the uterine cavity, there is a notable lack
of studies8,10,11,15. We chose a longitudinal study where each
woman was examined on six different occasions throughout
the entire puerperium. In our opinion the regularity of the
involution changes are best revealed and described by means
of a longitudinal design.
In the early puerperium the transabdominal approach is to
be recommended. A large uterus cannot be imaged properly
using a transvaginal probe. Although a high frequency trans-
vaginal probe may better distinguish minor details, a relatively
short focal length limits its use during the early and middle
part of the puerperium. Therefore, we preferred to use the
transabdominal approach during the first four examinations,
on days 1, 3, 7 and 14 postpartum. In contrast, on days 28
and 56 postpartum, the uterus lies in the true pelvis and is
markedly decreased in size. On these occasions, the transvaginal
approach is preferable.
On days 1 and 3 postpartum the uterus has an angulated
form. It lies in a slightly retroverted position and arches over
the sacral promontory. The angulation is situated just above
the internal os. This position of the uterus is probably due to
a heavy corpus, a hypotonic lower segment in combination
with the supine position of the examined women. Wachsberg
Figure 3 Transabdominal, longitudinal scans of the uterus from an uncomplicated puerperium on days 1 (a, b, c) and day 3 (d). On day 1, in (a),
the whole cavity is seen as a thin white line; in (b) the cavity is thicker and shows a more heterogeneous pattern; in (c) a heterogeneous echo pattern
is seen with solid and fluid components in the cervical area.
Ultrasound in Obstetrics and Gynecology
Mulic-Lutvica et al.
et al.16 pointed out the impact of uterine angulation on the
measurements of uterine length. This artifact can be avoided
if the woman is in a semireclining position during the exam-
ination (Figure 1a). Between days 7 and 14 the shape of the
uterus is oval. It rotates about 100180 along the internal
os towards an anteverted position, which can be due to a
decrease in size of the uterus, contractions, and the formation
of a firm isthmus (Figure 6). In 12% of our cases the uterus
remained in a retroverted position.
The AP diameter of the uterus diminished substantially
and progressively during the puerperium and reached non-
pregnant dimensions between 4 and 8 weeks postpartum.
These findings are in accordance with previous reports15,18.
Defoort et al.9 concluded that the AP diameter is not an
appropriate parameter for assessing the involution. In our
opinion, however, the maximum AP diameter in the longi-
tudinal section seems to be a suitable measurement with
which to estimate the involution process; it is easy to obtain
and is only marginally subjected to distortion.
During the first 3 days postpartum the cavity is very thin,
probably due to the lifesaving contractions of the myo-
metrium. The walls are in close proximity. The thickness of
this line depends on the amount of retained decidua. More or
less decidua can be retained1,19,20 and after normal deliveries
495
Ultrasound in puerperium
the variation in sonographic appearance of the cavity could
be seen as a demonstration of these physiological variations
in retained decidua. The bright thin line seen on ultrasound
might possibly represent cases in which only the basal decidual
layer is retained, whereas the thicker and more irregular lines
Figure 4 Transabdominal, longitudinal scans of the uterus during
uncomplicated puerperium on days 7 (a) and 14 (b, c). On day 7, the
uterus is oval, anteverted and a heterogeneous pattern with fluid and
solid components is seen in the whole cavity. On day 14, in (b), the uterus
has an oval shape and is anteverted and fluid is seen in the whole uterine
cavity; in (c), a hyperechogenic focus (arrow) with reverberation artifact
is seen in the lower uterine segment.
496
Mulic-Lutvica et al.
might represent cases with retention of the spongy decidual
layer and, perhaps, fragments of membranes. In the early
puerperium it is uncommon to find fluid or an echogenic
mass in the cavity. A mixed echo pattern with fluid and solid
components was only seen in the cervical area, probably
Figure 5 Transvaginal scans of the uterus during normal puerperium on
days 28 (a, b) and 56 (c). On day 28, in (a), the uterus has an oval shape
and an anteverted position and the cavity is empty. The endometrium is
seen as a thin, bright line; in (b), a small amount of fluid separates the
uterine walls. On day 56, in (c), the involution process is completed and
the uterus has achieved non-pregnant dimensions and appearance. The
endometrium is seen as a thin, bright line.
Ultrasound in Obstetrics and Gynecology
Ultrasound in puerperium
(b)
(a) (c)
(d)
Figure 6 Changes of the uterus and uterine cavity throughout a normal
puerperium. (a) Days 13: Uterus is retroverted. The cavity is seen as a
thin white line in the upper part. The cervical area is expanded with fluid
and solid contents. (b) Day 7: Uterus is upright. Abundant fluid or mixed
contents are seen in the whole cavity. (c) Day 14: The uterus is anteverted
and the appearance of the uterus and cavity is similar to that on day 7.
(d) Days 28 and 56: Uterus is considerably decreased in size, the cavity
is empty and appears as a thin white line. It can be noted that the uterus
rotates about 100 180 along the internal cervical os from a retroverted
position on days 1 and 3 (a) to a mid-position on day 7 (b) to an
anteverted position on days 14 (c), and 28 and 56 (d).
reflecting a collection of blood, blood clots and parts of
membranes (Figure 3c). This was usually expelled and was
not seen on the following occasion. Independently of this
finding, all women had an uneventful puerperal course. Our
results agree with recently published findings12,13.
Increased values of the cavity diameters were measured
5 cm from the fundus on days 7 and 14, and fluid or mixed
echo patterns were seen in the whole cavity. This finding is
probably due to the presence of a necrotic decidual cast
which separates the uterine walls, reflecting a normal healing
process of the uterine cavity and an abundant shedding of
lochia. It was found in a majority of women even when the
cavity was empty in the immediate puerperium. On days 28
and 56 the cavity is seen as a very thin white line from the
fundus to the internal os. This corresponds to an inactive
endometrium seen during menopause or the early prolifera-
tive phase of the menstrual cycle, and reflects the completed
involution of the uterus and the hypoestrogenic state of the
puerperium. Endometrial fluid or a heterogeneous pattern
are rare findings during the late puerperium. Our results
concerning cavity dynamics during the puerperium are in
accordance with histological studies of the puerperal uterus
published by Williams in 193119. They also agree with a
recent report by Tekay and Jouppila13.
There are conflicting data about the presence of gas in the
uterine cavity during the normal puerperium10,15,17,18. Ultra-
sound appearance of gas is seen as an intensively hyperecho-
genic focus equivalent in echogenicity to bowel gas with clean
or dirty shadowing or a reverberation artifact17,21,22. Previous
studies have suggested a correlation between gas and infection
caused by Escherichia coli and Clostridium perfringens10,15.
On the other hand, Wachsberg and Kurtz detected gas in
about 21% of a normal population17. Other investigators have
not been able to confirm this to any particular extent12,13,23.
Our results indicate that gas is occasionally seen in the uterine
cavity after normal vaginal delivery and that it always disappears
within 1 or 2 weeks24. The presence of hyperechogenic dots
in the cavity need not necessarily be caused by gas. A small
amount of retained membranes possibly undergoes regres-
sive changes and might be the cause of hyperechogenic foci,
especially during the later part of the puerperium.
Ultrasound in Obstetrics and Gynecology
Mulic-Lutvica et al.
CONCLUSION
In spite of the great variations of the normal ultrasound appear-
ance of the puerperal uterus some findings are representative
for early, middle and late puerperium. Accumulation of fluid
and debris in the uterine cavity is a common and insignificant
finding of the involuting uterus. It is located in the cervical
area in the early puerperium and in the whole uterine cavity
in the middle part of the puerperium. In the early puerperium
the cavity, apart from the cervix, is most often seen on ultra-
sound as a thin white line. The same image is typical for the
late puerperium.
ACKNOWLEDGMENTS
We are grateful to the Ultrasound Foundation at the Depart-
ment of Obstetrics and Gynaecology, Uppsala University
Hospital, for financial support. We also wish to thank Henric
Nilsson for assistance with the statistical analysis.
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