Subinvolution of uterus
ICD-10 N85.3 is a billable code used to indicate a diagnosis of subinvolution of uterus.
Subinvolution of the uterus refers to the failure of the uterus to return to its normal size and condition following childbirth. This condition typically occurs in the postpartum period and can lead to complications such as prolonged vaginal bleeding, infection, and uterine atony. The uterus normally involutes, or shrinks, after delivery due to hormonal changes and the expulsion of the placenta. In cases of subinvolution, the uterine muscle fibers do not contract effectively, which can be attributed to retained placental tissue, infection, or other underlying conditions. Clinically, patients may present with symptoms such as abnormal uterine bleeding, pelvic pain, and signs of infection. Diagnosis is often made through clinical examination and imaging studies, such as ultrasound, to assess the size of the uterus and rule out retained products of conception. Management may include medical treatment with uterotonics or surgical intervention if necessary. Understanding this condition is crucial for healthcare providers to prevent complications and ensure proper postpartum care.
Detailed documentation of postpartum assessments, including uterine size and condition, any interventions performed, and follow-up care.
Postpartum patients presenting with abnormal bleeding or pelvic pain, requiring evaluation for subinvolution.
Ensure that all relevant clinical findings and imaging results are documented to support the diagnosis.
Comprehensive history and physical examination notes, including patient-reported symptoms and any referrals made.
Patients presenting for routine postpartum follow-up with complaints of prolonged bleeding or pain.
Coordination with obstetric specialists may be necessary for management and documentation of care.
Used for follow-up visits in postpartum patients, especially those with complications like subinvolution.
Document the reason for the visit, clinical findings, and any interventions performed.
Obstetricians should ensure comprehensive documentation to support the visit.
Common symptoms include abnormal vaginal bleeding, pelvic pain, and signs of infection such as fever or malaise. Patients may also report fatigue and lightheadedness due to blood loss.
Diagnosis is typically made through a combination of clinical examination, patient history, and imaging studies such as ultrasound to assess uterine size and rule out retained products of conception.
Treatment may include medical management with uterotonics to promote uterine contraction, monitoring, and in some cases, surgical intervention if there is retained tissue or severe complications.
While both conditions involve inadequate uterine contraction, subinvolution specifically refers to the failure of the uterus to return to its normal size postpartum, often due to retained tissue or infection, whereas atony refers to a lack of muscle tone leading to bleeding.
