Persistent Uterine Bleeding 3 Weeks After Miscarriage
Persistent bleeding 3 weeks after miscarriage is abnormal and requires immediate ultrasound evaluation to assess for retained products of conception (RPOC), which is the most common cause of late postpartum/post-miscarriage hemorrhage occurring between 24 hours and 6 weeks. 1
Immediate Diagnostic Evaluation
Transvaginal ultrasound with color Doppler is the first-line diagnostic test to evaluate for RPOC, endometritis, or other complications. 1
Key Ultrasound Findings to Assess:
RPOC appears as an echogenic endometrial mass with vascularity on Doppler imaging—the combination of echogenic tissue plus vascular flow is the most diagnostic finding. 1
Endometrial thickness up to 2.0-2.5 cm can be normal in the early post-miscarriage period, but thickened endometrium with fluid, gas, and debris suggests endometritis. 1
Absence of vascularity does not exclude RPOC, as some retained tissue may be avascular, making diagnosis challenging even on multiphase imaging. 1
Critical Pitfall:
- Complete miscarriage should never be diagnosed by ultrasound alone—you need serial quantitative beta-hCG measurements to confirm resolution, as 45% of women with clinical assessment suggesting complete miscarriage will have retained tissue on ultrasound. 2
Management Based on Findings
If RPOC is Confirmed:
Medical management with misoprostol (vaginal or oral) is an acceptable alternative to surgical evacuation, with success rates of 96% for both approaches in incomplete miscarriage. 3
Surgical evacuation remains definitive treatment if medical management fails or if bleeding is heavy enough to cause hemodynamic instability. 1, 4, 3
Obtain complete blood count to assess for anemia requiring iron supplementation or transfusion if hemoglobin has dropped significantly. 5
If Endometritis is Suspected:
Endometritis is a clinical diagnosis (fever, uterine tenderness, foul discharge) with nonspecific ultrasound findings of thickened heterogeneous endometrium with fluid and debris. 1
RPOC is strongly associated with chronic endometritis—62% of women with retained tissue develop chronic endometritis compared to 30% without RPOC. 6
Antibiotic therapy is indicated if clinical signs of infection are present, and pathologic evaluation for chronic endometritis should be performed on any tissue removed. 6
When to Escalate Care
Seek immediate evaluation if any of the following occur:
- Heavy bleeding (soaking through a pad per hour) 5
- Severe abdominal pain 5
- Fever or signs of systemic infection 1
- Hemodynamic instability (hypotension, tachycardia) 1
Additional Considerations
CT imaging with IV contrast is reserved for hemodynamically unstable patients or when ultrasound is inconclusive and there is concern for intra-abdominal hemorrhage, though CT cannot reliably distinguish RPOC from blood products. 1
Serial beta-hCG monitoring is essential—levels should decline appropriately after miscarriage, and failure to decline suggests persistent trophoblastic tissue. 5, 2
Coagulopathy screening may be warranted if there is concern for underlying bleeding disorder, particularly in women with recurrent pregnancy loss, as 55% of recurrent miscarriages are caused by procoagulant defects. 7