What is the appropriate evaluation and management for an 8-week postpartum female with new onset pink vaginal bleeding for 2 weeks without fever or abdominal pain?

Evaluation and Management of 8-Week Postpartum Vaginal Bleeding

For an 8-week postpartum woman with 2 weeks of pink vaginal bleeding after cesarean delivery without fever or abdominal pain, begin with transvaginal ultrasound to evaluate for retained products of conception (RPOC), cesarean scar complications, or vascular abnormalities, as these are the most common causes of late postpartum hemorrhage. 1

Differential Diagnosis

The most likely etiologies at 8 weeks postpartum include:

• Retained products of conception (RPOC) - Most common cause of late postpartum hemorrhage, more likely after vaginal delivery but still occurs after cesarean 2, 1
• Subinvolution of placental bed - Failure of normal uterine involution 2
• Postpartum endometritis - More common after cesarean section than vaginal delivery, though typically presents with fever and foul-smelling discharge 1
• Cesarean scar defects - Occur in 24-88% of women after cesarean and may cause abnormal bleeding patterns 1
• Vascular complications - Pseudoaneurysms or arteriovenous malformations (AVMs), which can present with intermittent bleeding 2, 1, 3
• Normal menstrual return - Can occur by 6-8 weeks postpartum in non-breastfeeding women 2

Initial Workup

History and Physical Examination

Obtain focused history for:

• Delivery mode and complications - Cesarean increases risk of scar complications and endometritis 1
• Breastfeeding status - Affects timing of menstrual return 2
• Quantity and character of bleeding - Pink bleeding suggests lighter flow; heavy bleeding with clots suggests RPOC or vascular abnormality 1
• Associated symptoms - Severe pain suggests RPOC or scar complications; fever/foul discharge indicates endometritis 1

Perform pelvic examination to:

• Assess cervix - Look for cervical polyps, cervicitis, or lacerations 2
• Evaluate uterine size and tenderness - Enlarged tender uterus suggests RPOC or endometritis 1

Laboratory Studies

• Complete blood count - Assess for anemia from ongoing blood loss 1
• Coagulation studies if bleeding is heavy - Rule out coagulopathy, though rare 2, 4

Imaging

Transvaginal ultrasound is the primary diagnostic tool 1:

• For RPOC: Look for vascular echogenic endometrial mass or endometrial thickness >8-13 mm 1
• Add color Doppler: Identifies vascular RPOC requiring intervention and can detect pseudoaneurysms (hypoechoic masses with turbulent flow) 1, 3
• Evaluate cesarean scar: Assess for dehiscence or defects, though normal scar appearance can be difficult to distinguish from dehiscence on ultrasound 1

Management Algorithm

If Hemodynamically Stable with Light Bleeding (Most Likely Scenario)

1. Obtain transvaginal ultrasound with Doppler 1
2. If normal findings: Likely normal menstrual return; counsel that postpartum menstrual patterns may differ from pre-pregnancy 1
3. If RPOC identified without significant vascularity: Consider ultrasound-guided gentle suction curettage 1
4. If vascular RPOC or pseudoaneurysm: Refer for uterine artery embolization as first-line treatment for women desiring future fertility 3

If Concerning Features Present (Heavy Bleeding, Pain, Fever)

1. Obtain baseline labs (CBC, coagulation studies) 1
2. Perform immediate transvaginal ultrasound with Doppler 1
3. If endometritis suspected: Start broad-spectrum antibiotics; ultrasound can identify complications like abscess 2
4. If significant RPOC: Ultrasound-guided gentle suction curettage 1

If Hemodynamically Unstable

1. Initiate aggressive resuscitation with crystalloid and blood products 1
2. Activate massive transfusion protocol if blood loss exceeds 1,500 mL 5
3. Obtain stat labs including type and cross, CBC, coagulation panel 1
4. Consider CT angiography if ultrasound unavailable or to localize active extravasation 2
5. Proceed to interventional radiology for embolization or operating room for surgical management 2, 3

Critical Pitfalls to Avoid

• Never perform blind digital examination before excluding vascular abnormalities or low-lying placenta with imaging 1
• Avoid aggressive sharp curettage that could perforate the thinned cesarean scar if RPOC removal is needed 1
• Do not assume absence of menstruation guarantees lack of fertility - ovulation can occur before first menses 1
• Do not delay imaging in persistent bleeding - vascular complications like pseudoaneurysms can be life-threatening if ruptured 3

Follow-Up

• If normal menstrual return diagnosed: Reassure and counsel on contraception, as fertility returns rapidly 2, 1
• If RPOC treated: Maintain close monitoring for 24-48 hours with serial hemoglobin checks and watch for delayed complications 1
• If vascular abnormality treated with embolization: Follow-up imaging to confirm resolution; hysterectomy may be needed if embolization fails 3