Boggy uterus

Boggy uterus also known as uterine atony or hypotonic uterus, is when the uterus doesn’t contract (tighten) as strongly as it should after the placenta is delivered after your baby is born. Normally, uterine contractions help stop the bleeding after the placenta separates from the uterus. But when these contractions aren’t strong enough, hemorrhage can happen. Signs and symptoms of uterine atony or “boggy uterus” include heavy bleeding and not having contractions after giving birth. A boggy uterus after delivery complicates 1 in 40 births in the United States and is responsible for at least 75% of cases of postpartum hemorrhage ¹. Postpartum hemorrhage is defined as ≥500 ml blood loss within 24 hour of vaginal delivery or 1000 ml loss within 24 hour of cesarean section ². Postpartum hemorrhage is the leading cause of maternal mortality worldwide. But prompt recognition of the problem, and effective management with uterine massage, uterotonic drugs, and/or other crucial interventions, can arrest post-delivery bleeding.

Boggy uterus or uterine atony is defined as failure of the myometrium to contract and retract around the open blood vessels of the uteroplacental implantation site following childbirth ³. Myometrial contractions are vital to safeguard against excessive (and, potentially fatal) blood loss. But if the urgent obstetrical situation is mishandled, or if the response is not well-timed, the ensuing result can be traumatic. Delays in establishing an accurate diagnosis, failing to perform adequate maneuvers and/or employing poor team communication strategies may lead to catastrophic patient outcomes.

Diagnosis of diffuse uterine atony or boggy uterus is prompted typically by finding of more than usual blood loss during examination demonstrating a flaccid and enlarged uterus, which may contain a significant amount of blood. With focal localized atony, the fundal region may be well contracted while the lower uterine segment is dilated and atonic, which may difficult to appreciate on abdominal examination, but may be detected on vaginal examination. A digital exploration of the uterine cavity (if adequate anesthesia is available), or bedside obstetric ultrasound imaging to reveal an echogenic endometrial stripe is an essential examination, as is a timely examination with adequate lighting to exclude an obstetric laceration.

The Joint Commission recommends that obstetrical staff undergo interprofessional team training to teach staff to work together and communicate more effectively when postpartum hemorrhage (most due to uterine atony) occurs. The Commission is in favor of clinical drills to help staff prepare for the clinical event, as well as conducting debriefings after such events to evaluate team performance and identify areas for improvement. Simulation team training can help to identify areas that need strengthening, and regular, unannounced, simulated, postpartum hemorrhage scenarios in real-life settings, such as the labor and delivery units or post-anesthesia care units, may also increase comfort with the protocols and teamwork required in such emergencies. Such a systemic approach creates a positive trajectory toward improved obstetric outcomes and is also endorsed by the Association of Women’s Health, Obstetric and Neonatal Nurses. An interprofessional team approach will provide the best patient outcomes.

Boggy uterus or uterine atony should always be treated empirically in the early postpartum period ⁴. Uterine massage will stimulate uterine contractions and frequently stops uterine hemorrhage. The examiner’s gloved hand can be placed into the lower uterus, extracting any large clots or tissue that prevent adequate contractions.

Do not apply excessive pressure on the fundus of the uterus as this may increase the risk of inversion. Note that massaging a hard, contracted uterus can actually impede detachment of the placenta and increase bleeding.

With a boggy uterus, continue to massage and administer uterotonics to increase uterine contraction. Give oxytocin, an analogue of the identically named endogenous hormone, 20-40 units in 1 L lactated Ringer at 600 mL/h to maintain uterine contraction and to control hemorrhage. Ergotamines (eg, ergonovine, methylergonovine [Methergine]) can be used instead of, or with the failure of oxytocin, to facilitate uterine contraction ⁵. Other alternatives include 15-methyl-prostaglandin, also known as carboprost (Hemabate) (0.25 mg IM), and misoprostol (1 mg placed rectally), which is an inexpensive prostaglandin E1 analogue that has been used in several trials with good success in controlling postpartum hemorrhage in cases refractory to oxytocin. In settings in which oxytocin use is not feasible, misoprostol might be a suitable treatment alternative for postpartum hemorrhage ⁶.

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Figure 1. Technique of bimanual massage for uterine atony

Footnote: Bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall. The posterior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand.

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Boggy uterus adenomyosis

Adenomyosis is a gynecologic condition characterized by ectopic endometrial tissue within the uterine myometrium ⁸. Adenomyosis occurs when the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus. The displaced tissue continues to act normally — thickening, breaking down and bleeding — during each menstrual cycle. An enlarged uterus and painful, heavy periods can result. Historically, adenomyosis was a histologic diagnosis that required biopsy or more often hysterectomy. Presently, the diagnosis can be made non-invasively using ultrasound or MRI.

The cause of adenomyosis remains unknown, but the disease usually resolves after menopause. For women who have severe discomfort from adenomyosis, hormonal treatments can help. Definitive treatment for women who no longer desire pregnancy is removal of the uterus (hysterectomy) which cures adenomyosis, while a variety of other medical and minimally invasive therapies are available for those who want to preserve fertility or want to avoid more extensive surgery.

Adenomyosis complications

The correlation between adenomyosis and infertility is not clearly defined. While some authors cite an association of 11 to 12%, contradictory data also exists ⁹. Due to a multitude of confounders and variable diagnostic criteria for adenomyosis, no clear association has been established ¹⁰.

With more validated diagnostic imaging criteria of ultrasound in recent years, future research will be able to characterize associations between adenomyosis and infertility more confidently.

Adenomyosis diagnosis

Physical examination

The clinical diagnosis of adenomyosis is difficult as a variety of common gynecologic conditions share the signs and symptoms. The most common symptoms include heavy menstrual bleeding or painful menses. Clinical diagnostic accuracy is neither sensitive nor specific ¹⁰. Other less common symptoms include chronic pelvic pain and dyspareunia ⁹. It is also crucial to note that up to 33% of women with adenomyosis may be asymptomatic ⁹. While infertility is often considered a potential presenting symptom, the data is inconclusive with some sources reporting an association of 11 to 12% with adenomyosis ⁹.

Physical exam classically demonstrates a “boggy” enlarged uterus due to the combined effects of increased vascularization from ectopic endometrial tissue and smooth muscle proliferation ⁸. As compared to the enlarged leiomyomatous uterus, a tender uterus is more common ¹¹.

Laboratory tests

Laboratory testing is useful to rule out other disease entities included in the differential diagnosis, in addition to identifying certain complicating features such as anemia due to heavy menstruation. While some biomarkers due exist, none are specific for adenomyosis ¹⁰.

Imaging studies

Imaging is the primary means of making the diagnosis. Previously the preferred modality was MRI; however, recent data has shown the transvaginal ultrasound to match the sensitivity and specificity of MRI (89% sensitivity, 86% specificity) ¹². The availability of ultrasound and the increased costs of MRI have led to ultrasound becoming the preferred modality for the initial evaluation, reserving MRI for equivocal cases ¹³.

Ultrasound

Transvaginal ultrasound is the preferred diagnostic imaging modality for adenomyosis. The characteristic findings reflect the histopathologic changes of the disease process and can be broken down into three categories:

1. Endometrial infiltration: echogenic striations and nodules, myometrial cysts, and “lollipop” diverticula (cystic striations)
2. Smooth muscle proliferation: focal or diffuse myometrial thickening with indistinct borders more commonly involving the posterior fundus and heterogenous echotexture manifesting as “venetian blind” appearance of thin linear shadows
3. Vascularity: color Doppler demonstrating an increased number of tortuous vessels throughout the involved myometrium as opposed to leiomyomas which displace vessels

A number of mimics can have similar findings on the ultrasound exam, including tamoxifen use, prior endometrial ablation, endometriosis, uterine contractions, vascular malformations, leiomyomas, and cancer. Certain techniques such as low-frequency, coronal reconstructions, 3-D ultrasound, cine-clips, color Doppler, and saline infusion sonohysterography can be used to differentiate between these entities.

MRI

Characteristic findings on MRI parallel the same features seen on ultrasound ¹⁴:

• On T2-weighted imaging, uterine enlargement characterized by ill-defined, low-signal-intensity regions within the junctional zone is reflective of smooth muscle hyperplasia (junctional zone thicker than 12mm is generally accepted as diagnostic)
• T2 hyperintense myometrial cysts reflecting regions of ectopic endometrial tissue (can also have increased intrinsic T1 signal or increased susceptibility in hemorrhagic foci)
• Contrast enhancement is generally not reliable for assessment of vascularity as compared to color Doppler ultrasound

Similarly to ultrasound, a variety of mimics ranging from co-existing gynecologic pathologies to physiologic variants exist. Susceptibility weighted imaging, diffusion-weighted imaging, MR spectroscopy, cine MR imaging, and increased 3T field strength are all problem-solving strategies ¹⁵.

It is important to obtian the MRI in the late proliferative or secretory phase (days 7 to 28) due to the decreased signal of normal myometrium during the early proliferative phase (days 1 to 6) ¹⁵.

Adenomyosis treatment

The first consideration in treatment selection is the desire for fertility, which will guide treatment considerations. Hysterectomy is the definitive cure. The remaining options target the primary symptoms of heavy, painful menstrual bleeding while preserving the uterus.

Medical therapies

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the primary medical therapies. These medications target the cyclooxygenase enzyme which produces the prostaglandins responsible for painful cramping during menstruation ⁹.

Various hormonal therapies are available which include oral contraceptive pills (OCPs), levonorgestrel intrauterine device (IUD), danazol, and aromatase inhibitors. These therapies aim to reduce the estrogenic effects which lead to endometrial proliferation. Data to support a particular therapy lack well-powered randomly controlled trials; however, levonorgestrel IUDs are generally considered to be the primary therapy due to decreased side effect profile and overall success rates ⁹.

Minimally invasive/surgical therapies

Several interventional radiologic procedures exist which may be options for the patient who fail medical therapy but desire future fertility. MRI-guided and ultrasound-guided high-intensity ultrasound thermal ablation to target focal disease ¹⁶. Uterine artery embolization reduces blood flow to the uterus as a whole, thereby inducing necrosis leading to an overall reduction in uterine size ¹⁷. These therapies show promise but require additional data on direct treatment comparisons and long-term outcomes ¹⁰. While these therapies aim to preserve fertility, infertility is an understood risk.

Endometrial ablation may be considered in patients who do not desire future fertility but prefer a less invasive alternative to hysterectomy. Limitations include the ability to target deeper adenomyotic foci due to its superficial approach.

Myomectomy and partial hysterectomy are more invasive options that aim to preserve fertility. These options allow for targeting of deeper foci; however, subsequent scarring may lead to disease recurrence as the endometrial-myometrial interface is disrupted, a risk factor for adenomyosis. Additional considerations include the potential for future pregnancy complications due to altered uterine anatomy with an increased risk of uterine rupture, premature rupture of membranes, premature labor, and spontaneous abortion ¹⁰.

Hysterectomy remains the definitive cure for adenomyosis.

Adenomyosis prognosis

Adenomyosis is a difficult diagnosis to manage as multiple clinical factors must be considered, including fertility, confidence in diagnosis, side effects of medical management, and risk of invasive procedures. Recent data showing an increased prevalence of adenomyosis in younger populations and asymptomatic patients reflects a spectrum of disease which is incompletely understood. Symptoms seem to correlate with the number of adenomyosis foci and the depth of invasion ¹⁸. The consensus to treatment is a stepwise approach with medical therapy to include anti-inflammatory and hormonal agents with progression to minimally invasive procedures such as endometrial ablation/myomectomy or uterine artery embolization. The definitive cure remains hysterectomy.

Boggy uterus postpartum causes

Risk factors for boggy uterus or uterine atony include prolonged labor, precipitous labor, uterine distension (multi-fetal gestation, polyhydramnios, fetal macrosomia), fibroid uterus, chorioamnionitis, indicated magnesium sulfate infusions, and prolonged use of oxytocin ³. Ineffective uterine contraction, either focally or diffusely, is additionally associated with a diverse range of causes including retained placental tissue, placental disorders (such as morbidly adherent placenta, placenta previa, and abruption placentae), coagulopathy (increased fibrin degradation products) and uterine inversion. Body mass index (BMI) above 40 (morbidly obese or severe obesity) is also a recognized risk factor for postpartum uterine atony ¹⁹.

Boggy uterus pathophysiology

Contraction of the myometrium that mechanically compresses the blood vessels supplying the placental bed provides the principal mechanism uterine hemostasis after delivery of the fetus, and the placenta is concluded. The process is complemented by local decidual hemostatic factors such as tissue factor type-1 plasminogen activator inhibitor as well as by systemic coagulation factors such as platelets, circulating clotting factors.

Boggy uterus postpartum diagnosis

At prenatal history and examination, risk factor discernment is key to optimal risk management. Identification of risks allows for planning and availability of resources that might be needed including personnel, medication, equipment, adequate intravenous access, and blood products. The American College of Obstetricians recommends that women be identified prenatally as high risk for postpartum hemorrhage based on the presence of placenta accreta spectrum, pre-pregnancy BMI greater than 50, clinically significant bleeding disorder, or other surgical-medical high-risk factors. Part of the planning should be to develop a plan that allows delivery at a facility with an appropriate level of care for these patients’ needs.

The diagnosis is made during the physical exam immediately upon conclusion of an obstetric vaginal or cesarean delivery. Direct palpation at cesarean delivery (typically after the closure of the uterine incision) or indirect examination at bimanual examination after a vaginal delivery reveals a boggy, soft, and an unusually enlarged uterus, typically with co-existent bleeding from the cervical os (harder to appreciate at cesarean deliveries). An expeditious exclusion of retained gestational products or obstetric lacerations quickly excludes additional co-concomitant etiologies. The possibility of coagulopathies is considered and pursued if clinically indicated. The physical examination suggested above may involve obstetric ultrasound imaging.

Boggy uterus treatment

Prenatal readiness

If the woman is at a medium risk for intrapartum bleeding, blood should include be typed and screened. Women with a medium risk factor for uterine atony-related postpartum hemorrhage include prior uterine surgery, multiple gestation, grand multiparity, prior postpartum hemorrhage, large fibroids, macrosomia, body mass index greater than 40, anemia, chorioamnionitis, prolonged second stage, oxytocin longer than 24 hours, and magnesium sulfate administration. Those assessed to be high risk should be typed and cross-matched for those at high risk of postpartum hemorrhage. High-risk criteria include placental previa or accreta, bleeding diathesis, 2 or more medium risk factors for uterine atony. Use of a cell saver (blood salvage) should be considered for women at increased risk of postpartum hemorrhage, but this is not cost-effective to be routine.

Intrapartum prevention

This includes optimal management of the third stage of labor. Active management of the third stage includes uterine massage with concomitant sustained low-level traction on the umbilical cord. Simultaneous oxytocin infusion is helpful, although it is reasonable to defer it to after delivery of the placenta.

Initial medical treatment

If boggy uterus or uterine atony occurs, healthcare providers should be ready for initial medical management which is directed to the use of medications to improve uterine tone and induce uterine contractions. Massaging the uterus is also effective, as is ensuring an empty cavity. Maternal support with intravenous (IV) fluids is commenced through preferably an 8-gauge, intravenous catheter. A team approach is initiated with the summoning of the needed personnel through a standardized built-in alert system. Medications used for postpartum hemorrhage secondary to uterine atony include the following:

1. Oxytocin (Pitocin) can be given IV 10 to 40 units per 1000 ml or 10 units intramuscularly (IM). The rapid undiluted infusion may cause hypotension.
2. Methylergonovine (Methergine) given IM 0.2 mg. Given every 2 to 4 hours. Should be avoided in patients with hypertension.
3. 15-methyl-PGF2-alpha (Hemabate) given IM 0.25 mg. Given every 15 to 90 minutes for a maximum of 8 doses. Should be avoided in asthmatics. May cause diarrhea, fevers, or tachycardia. It is expensive.
4. Misoprostol (Cytotec): 800 to 1000 mg placed rectally. May cause a low-grade fever. It has a delayed action.
5. Dinoprostone (Prostin E2) 20 mg vaginal or rectal suppository may be given every 2 hours.

Surgical treatment

Should the medications fail with persisting excess bleeding, then surgical management is engaged ²⁰.

Tamponade techniques

1. Uterine packing with gauze (with vaginal packing to ensure its retention, thus a uterovaginal packing) with Foley catheter insertion to allow bladder drainage. The uterine packing should be tight and uniform, and it is a quickly and efficiently achieved with rolled gauze ribbons.
2. Bakri balloon (with vaginal packing to ensure its retention) with Foley catheter insertion to facilitate bladder drainage.

Surgical management techniques

1. Uterine curettage for retained products
2. Uterine artery ligation (O’ Leary), with an option to for extending arterial ligation to tubo-ovarian vessels.
3. Compression sutures such as the B-Lynch are typically reserved for clinical scenarios where bimanual compression of the uterus leads to arrest in bleeding.
4. Hypogastric artery ligation (performed by specialist OB/GYN)
5. Hysterectomy

Postoperative and rehabilitation care

Postpartum anemia is common after an episode of uterine atony and postpartum hemorrhage. Severe anemia due to postpartum hemorrhage may require red cell transfusions, depending on the severity of anemia and the degree of symptomatology attributable to anemia. A common practice is to offer a transfusion to symptomatic women with a hemoglobin value less than 7 g/dL. In most cases of uterine atony-related postpartum hemorrhage, the amount of iron lost is not fully replaced by the transfused blood. Oral iron should thus be also considered. Parenteral iron therapy is an option as it accelerated recovery. Most women with mild to moderate anemia, however, resolve the anemia sufficiently rapidly with oral iron alone and do not need parenteral iron.

Boggy uterus prognosis

Women with a prior postpartum hemorrhage have as much as a 15% risk of recurrence in a subsequent pregnancy. The risk of recurrence depends, in part, on the underlying cause and associations such as class 3 obesity may have a higher recurrence risk.

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