Heavy Vaginal Bleeding 21 Days Post-LSCS: Etiology and Management
Most Likely Diagnosis
Retained products of conception (RPOC) is the most common cause of late postpartum hemorrhage (occurring >24 hours to 6 weeks postpartum), particularly after cesarean section, with a prevalence of 24-88% in women after LSCS 1. However, uterine artery pseudoaneurysm must be urgently excluded before any intervention, as it can cause life-threatening hemorrhage and is specifically associated with post-cesarean bleeding 2, 3, 4.
Critical Differential Diagnoses
The key etiologies at 21 days post-LSCS include:
- RPOC: Most common cause of late PPH after cesarean, presents with intermittent or persistent bleeding 5, 1
- Uterine artery pseudoaneurysm: Life-threatening vascular complication occurring in 3-6 weeks post-cesarean, presents with sudden profuse bleeding 2, 3, 4
- Subinvolution of placental bed: Failure of normal uterine involution with persistent bleeding 1
- Postpartum endometritis: More common after cesarean than vaginal delivery, typically presents with fever and foul-smelling discharge 1
- Cesarean scar dehiscence/complications: Occurs in 24-88% of women post-cesarean 1
- Arteriovenous malformations (AVMs): Rare vascular abnormality causing intermittent bleeding 1, 3
Immediate Assessment Algorithm
Step 1: Hemodynamic Stabilization
- Assess vital signs immediately: Check for hypotension and tachycardia indicating active hemorrhage 2, 4
- Establish large-bore IV access and initiate resuscitation with crystalloids and blood products if hemodynamically unstable 5
- Obtain baseline labs: CBC, coagulation profile (PT/PTT, fibrinogen), type and crossmatch 5
Step 2: Focused Clinical Assessment
Obtain specific history for:
- Delivery complications: Prolonged labor, manual placental removal, difficult cesarean 1
- Bleeding pattern: Sudden profuse bleeding suggests pseudoaneurysm; intermittent bleeding suggests RPOC or AVM 1, 2
- Associated symptoms: Severe pain suggests scar complications; fever/foul discharge indicates endometritis 1
- Previous episodes: Recurrent bleeding episodes are characteristic of pseudoaneurysm 3, 4
Physical examination should assess:
- Uterine tone and size: Firm uterus rules out atony 6
- Presence of fever: Suggests endometritis 1
- Abdominal wall examination: Check for subcutaneous hematomas at cesarean scar site 4
Step 3: Diagnostic Imaging - MANDATORY BEFORE ANY INTERVENTION
Transvaginal ultrasound with color Doppler is the primary diagnostic tool and must be performed immediately 1:
For RPOC detection:
- Echogenic endometrial mass with vascularity on Doppler has 90-95% sensitivity and 95-98% specificity 1
- Endometrial thickness >2-2.5 cm is suggestive but nonspecific 5
- Color Doppler identifies vascular RPOC requiring intervention 1
For pseudoaneurysm detection:
- Look for hypoechoic/pulsatile mass with "yin-yang" or swirling pattern on color Doppler 5, 2
- Turbulent flow within myometrium (not extending to endometrium like RPOC) 5
- This finding is CRITICAL as it changes management completely 2
If ultrasound is inconclusive and patient is hemodynamically stable:
- CT angiography with IV contrast can localize bleeding source and identify vascular complications 5
- Multiphasic CT useful for detecting active extravasation 5
Management Algorithm Based on Diagnosis
If Pseudoaneurysm Identified:
Uterine artery embolization (UAE) is the first-line treatment 2, 3, 4:
- Success rate >90% for controlling hemorrhage 3
- Preserves fertility 3
- DO NOT perform dilation and curettage - this can cause catastrophic hemorrhage 2
If UAE unavailable or patient hemodynamically unstable:
- Surgical ligation of internal iliac artery is effective alternative 3, 4
- Hysterectomy reserved for life-threatening hemorrhage unresponsive to other measures 3
If RPOC Identified Without Significant Vascularity:
Ultrasound-guided gentle suction curettage has 80-90% success rate 1:
- Avoid aggressive sharp curettage due to risk of perforating thinned cesarean scar 1
- Perform under ultrasound guidance 1
- Never perform blind curettage without excluding vascular abnormalities first 1
Medical management alternative:
- Misoprostol 600-800 mcg can be considered for small RPOC
- Less effective than surgical removal for significant RPOC
If Endometritis Diagnosed:
- Broad-spectrum IV antibiotics: Clindamycin 900mg IV q8h plus gentamicin 5mg/kg IV q24h 1
- Continue until afebrile for 24-48 hours
- Imaging to exclude concurrent RPOC 1
If Subinvolution of Placental Bed:
- Methylergonovine 0.2mg PO TID for uterine contraction
- Tranexamic acid 1g IV/PO TID for antifibrinolytic effect 5
- Close monitoring for response
Critical Pitfalls to Avoid
NEVER perform blind digital examination or curettage before imaging excludes vascular abnormalities - this can cause life-threatening hemorrhage from pseudoaneurysm rupture 1, 2
Do not assume RPOC and proceed to D&C without Doppler ultrasound - pseudoaneurysm mimics RPOC but requires completely different management 2
Do not delay imaging in hemodynamically stable patients - early diagnosis of pseudoaneurysm prevents catastrophic bleeding 2, 3
Avoid aggressive sharp curettage - the cesarean scar creates a thinned area prone to perforation 1
Do not dismiss recurrent bleeding episodes - this pattern is characteristic of pseudoaneurysm and requires vascular imaging 3, 4
Postoperative Hemorrhage Management Principles
If bleeding is massive (>1500 mL):
- Activate massive transfusion protocol: Transfuse packed RBCs, FFP, and platelets in 1:1:1 ratio 5
- Re-dose prophylactic antibiotics 5
- Keep patient warm (>36°C) and avoid acidosis - coagulation factors function poorly in hypothermia 5
- Consider tranexamic acid 1g IV if hyperfibrinolysis suspected 5
- Transfer to ICU for intensive monitoring 5