Differential Diagnosis for 1 Day Heavy Vaginal Bleeding in a 2 Months Postpartum Breastfeeding Woman

• Single Most Likely Diagnosis
  • Postpartum hemorrhage (PPH) or delayed postpartum hemorrhage: This condition is a leading cause of maternal morbidity and mortality. Heavy bleeding 2 months postpartum could be due to retained placental tissue, infection, or other complications that were not immediately apparent after delivery. The fact that the patient is breastfeeding does not rule out this possibility, as PPH can occur even after the initial postpartum period.
• Other Likely Diagnoses
  • Endometritis: An infection of the uterine lining, which can cause heavy bleeding, especially in the postpartum period. Breastfeeding does not protect against this condition.
  • Uterine atony: Although less common 2 months postpartum, uterine atony (where the uterus fails to contract down effectively) can still occur, especially if there are retained products of conception or other uterine irritants.
  • Ovulation or menstrual cycle resumption: While less likely to cause soaking a pad every hour, the resumption of menstrual cycles can sometimes be heavy, especially in breastfeeding women whose cycles may be irregular.
• Do Not Miss Diagnoses
  • Uterine rupture or dehiscence: Although rare, especially if the patient did not have a uterine scar from a previous cesarean section, this condition is life-threatening and requires immediate surgical intervention.
  • Malignancy (e.g., choriocarcinoma): Rare but potentially deadly, malignancies can cause abnormal uterine bleeding. The postpartum period is a time when such conditions might become apparent.
  • Coagulopathy: Disorders of blood clotting can lead to severe bleeding and are critical to diagnose and treat promptly to prevent severe morbidity or mortality.
• Rare Diagnoses
  • Arteriovenous malformation (AVM): A rare condition that can cause heavy, life-threatening bleeding. It might not be immediately suspected but is crucial to consider in cases of unexplained severe bleeding.
  • Uterine inversion: More commonly associated with immediate postpartum hemorrhage, uterine inversion can still occur and is a medical emergency.
  • Placenta accreta spectrum (PAS) disorders: While typically diagnosed antenatally or immediately postpartum, in some cases, symptoms might be delayed, especially if there is partial placenta accreta.