What is the management approach for an 8-week postpartum woman with persistent vaginal bleeding after a vaginal delivery?

Management of Persistent Vaginal Bleeding at 8 Weeks Postpartum After Vaginal Delivery

For an 8-week postpartum woman with persistent vaginal bleeding after vaginal delivery, begin immediate evaluation with transvaginal ultrasound with Doppler to identify the most common causes: retained products of conception (RPOC), subinvolution of the placental bed, endometritis, or vascular uterine abnormalities. 1, 2

Initial Clinical Assessment

Assess hemodynamic stability first - check vital signs, blood pressure, heart rate, and estimate current blood loss to determine urgency of intervention. 3, 4

Key historical features to elicit:

• Bleeding pattern: sudden increase versus persistent heavy flow versus intermittent bleeding (intermittent bleeding suggests vascular abnormality) 5
• Associated symptoms: fever/chills (suggests endometritis), pelvic pain, foul-smelling discharge 1
• Risk factors: history of uterine instrumentation, cesarean section, manual placental removal, or retained placenta 2, 5

First-Line Imaging: Transvaginal Ultrasound with Doppler

Transvaginal ultrasound with color Doppler is the initial imaging modality of choice for late postpartum hemorrhage (>24 hours to 6 weeks). 1

What to Look For:

Retained Products of Conception (RPOC):

• Echogenic endometrial mass with vascularity on Doppler 1, 4
• RPOC typically extends to the endometrium 1
• Pitfall: Absence of vascularity does not exclude RPOC, as it can be avascular 1

Vascular Uterine Abnormalities (VUA) and Pseudoaneurysm:

• Swirling or "yin-yang" pattern of blood flow within a hypoechoic structure 1
• Pseudoaneurysm is restricted to the myometrium (unlike RPOC which extends to endometrium) 1
• Pitfall: Difficult to distinguish acquired VUA from subinvolution of placental bed vessels on ultrasound alone 1

Normal Postpartum Findings (Do Not Overinterpret):

• Endometrial debris and gas present in 20-25% of normal postpartum women 1, 2
• Thickened endometrial echo complex up to 2-2.5 cm is nonspecific in early postpartum period 1, 2
• Echogenic material in uterine cavity without vascularity may be normal 6

Management Based on Etiology

If RPOC Identified:

Surgical evacuation (dilation and curettage) is indicated for symptomatic retained products causing persistent bleeding. 3, 4

If Vascular Abnormality (Pseudoaneurysm/AVM) Suspected:

• Do NOT perform blind curettage - risk of catastrophic hemorrhage 5
• Uterine artery embolization (UAE) is first-line treatment for women desiring future fertility 5
• If UAE fails, hysterectomy may be necessary 5

If Endometritis Suspected (fever, pain, foul discharge):

• Broad-spectrum IV antibiotics 1
• Consider advanced imaging (MRI or CT) if abscess or infected hematoma suspected 1

If Subinvolution of Placental Bed:

• Trial of methylergonovine 0.2 mg IM (if not hypertensive - contraindicated in hypertension >10% risk of severe vasoconstriction) 4
• Alternatively, misoprostol or other uterotonics 3

When to Escalate Imaging

Obtain CT with IV contrast or MRI if:

• Ultrasound findings are equivocal 1
• Suspected deep pelvic hematoma, abscess, or ovarian vein thrombosis 1, 7
• Need to localize bleeding source for interventional radiology planning 1, 4
• Hemodynamically stable patient with persistent bleeding despite initial management 1, 4

MRI advantages over CT/US:

• Superior detection of myometrial defects and uterine dehiscence 1
• Better localization of deep-seated pelvic hematomas (supralevator vs infralevator) 1
• Can identify pseudoaneurysm sac more specifically 1

Hemodynamically Unstable Patient

If patient is hemodynamically unstable with ongoing hemorrhage:

• Initiate massive transfusion protocol if blood loss >1500 mL 3, 4
• Administer tranexamic acid 1g IV over 10 minutes (even at 8 weeks postpartum if acute bleeding) - though benefit decreases significantly beyond 3 hours from bleeding onset 3, 4
• Maintain normothermia - warm all fluids and blood products 3, 4
• Consider intrauterine balloon tamponade for temporization 3, 4
• Proceed directly to interventional radiology for arterial embolization or surgical exploration 3, 4

Critical Pitfalls to Avoid

• Do NOT perform curettage if vascular abnormality suspected - obtain Doppler ultrasound first 5
• Do NOT dismiss echogenic material in uterus as always pathologic - common normal finding in first 6 weeks 1, 2, 6
• Do NOT give methylergonovine to hypertensive patients - risk of severe vasoconstriction 4
• Do NOT delay evaluation beyond 6 weeks - bleeding continuing or increasing beyond 6 weeks requires investigation 2

Monitoring and Follow-up

• Continue hemodynamic monitoring for at least 24 hours after any intervention 3, 4
• Monitor for complications: infection, renal failure, Sheehan syndrome 3, 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 3, 4