What is the likely cause of a significant drop in hemoglobin (Hgb) levels from 9.7 to 5.5 in a postpartum female 48 hours after cesarean section (c/s), with normal lochial discharge, normal blood pressure, tachycardia, and no reported symptoms of anemia or pain?

Differential Diagnosis of Progressive Postpartum Anemia After Cesarean Section

The most likely causes of this dramatic hemoglobin drop from 9.7 to 5.5 g/dL with normal lochia and vital signs are concealed hemorrhage (intra-abdominal hematoma, broad ligament hematoma, or retroperitoneal bleeding) or acute hemolysis from a thrombotic microangiopathy such as atypical hemolytic uremic syndrome (aHUS). 1, 2

Immediate Diagnostic Workup Required

Rule Out Concealed Hemorrhage First

• Perform urgent pelvic ultrasound with color Doppler to identify retained products of conception, hematoma formation (particularly broad ligament or intraperitoneal collections), or vascular abnormalities that could explain ongoing occult blood loss 1, 2
• Transvaginal ultrasound is superior for identifying vascular retained tissue at the cesarean scar site 2
• Normal lochia does NOT exclude significant concealed bleeding—intra-abdominal or retroperitoneal hematomas can accumulate without external blood loss 1
• The tachycardia (HR 111) with normal blood pressure suggests compensated hypovolemia, though the Shock Index (HR ÷ SBP) should be calculated; a value >1 indicates hemodynamic instability 1

Evaluate for Hemolysis Immediately

• Order peripheral blood smear stat to look for schistocytes, which indicate microangiopathic hemolytic anemia—a hallmark of thrombotic microangiopathy 1, 2
• Check haptoglobin (will be low if hemolysis occurring) and LDH (elevated with hemolysis) 1, 2
• Perform direct Coombs test to exclude autoimmune hemolysis 1, 2
• Assess reticulocyte count to evaluate bone marrow response 1

Critical Coagulopathy Assessment

• Measure fibrinogen level urgently: normal postpartum is 4-6 g/L; <2 g/L suggests consumptive coagulopathy 3, 1, 2
• Obtain PT/APTT and platelet count to assess for delayed coagulopathy 1, 2
• If thrombocytopenia is worsening beyond day 5 postpartum with persistent hemolysis, immediately measure ADAMTS13 activity level and consider atypical hemolytic uremic syndrome (aHUS), which has high mortality without complement blockade but excellent outcomes with eculizumab 1, 2
• ADAMTS13 levels <10% indicate thrombotic thrombocytopenic purpura (TTP) requiring plasma exchange 2

Expected Hemoglobin Response and Transfusion Needs

Transfusion Requirements

• Each unit of packed red blood cells should increase hemoglobin by approximately 1 g/dL, so if the patient received 2 units, expect Hb to rise to approximately 6.6-6.8 g/dL 1, 2
• Recheck hemoglobin 4-6 hours after transfusion completion to confirm adequate response and determine if additional transfusion is needed 1
• If hemoglobin remains <7.0 g/dL after transfusion, transfuse additional units immediately regardless of symptoms, transfusing one unit at a time with reassessment between units unless there is active hemorrhage 1, 4, 2

Monitoring Parameters

• Monitor vital signs every 1-2 hours for the first 24 hours after transfusion, watching specifically for signs of transfusion reactions or volume overload 1
• Monitor urine output closely, as oliguria may indicate ongoing hypovolemia or development of complications 1
• Serial CBC should be performed every 6-12 hours until stable 2

Common Pitfalls and Critical Considerations

Why Normal Lochia is Misleading

• Visual estimation of blood loss consistently underestimates actual loss; measure cumulative blood loss using volumetric techniques 1, 4
• Postpartum hemorrhage can be entirely concealed in the peritoneal cavity, broad ligament, or retroperitoneum after cesarean section 1
• The combination of preoperative anemia (Hgb 9.7) and postpartum hemorrhage are strong independent risk factors for severe postpartum anemia 5

Hemolysis Must Be Excluded

• The asymptomatic presentation despite Hgb 5.5 g/dL suggests chronic compensation, but this degree of anemia with tachycardia warrants immediate investigation for acute hemolysis 6
• Daily LDH, haptoglobin, and bilirubin should be monitored if hemolysis is suspected 2
• Platelet transfusion is contraindicated if TTP is suspected (ADAMTS13 <10%) as it may worsen thrombosis 2

Thromboprophylaxis Timing

• Initiate prophylactic low-molecular-weight heparin (LMWH) once hemostasis is secured and platelet count >50,000/μL, given post-cesarean status and day 5 postpartum 3, 2
• LMWH should be continued until hospital discharge at minimum, with consideration for extended prophylaxis up to 6 weeks postpartum 2

Additional Management

Iron Repletion

• Intravenous iron should be initiated after acute bleeding is controlled and hemolysis excluded, with a total dose of 800-1500 mg 2

Volume Overload Risk

• Monitor carefully for signs of transfusion-associated circulatory overload (TACO), particularly if the patient has preeclampsia or cardiac disease 1
• Transfuse one unit at a time and recheck hemoglobin before each subsequent unit unless there is active hemorrhage 1, 4