Evaluation and Management of Postpartum Vaginal Bleeding

Differential Diagnosis

The American College of Radiology suggests that retained products of conception (RPOC) are the most common cause of late postpartum hemorrhage, more likely after vaginal delivery but still occurs after cesarean, with a prevalence of 24-88% in women after cesarean 1, 2
The American College of Radiology recommends considering subinvolution of placental bed as a cause of postpartum hemorrhage, characterized by failure of normal uterine involution 2
The American College of Obstetricians and Gynecologists (ACOG) guidelines indicate that postpartum endometritis is more common after cesarean section than vaginal delivery, though typically presents with fever and foul-smelling discharge 1
The Society of Radiologists in Ultrasound states that cesarean scar defects occur in 24-88% of women after cesarean and may cause abnormal bleeding patterns 1
The American College of Radiology suggests that vascular complications, such as pseudoaneurysms or arteriovenous malformations (AVMs), can present with intermittent bleeding 2, 1
The Centers for Disease Control and Prevention (CDC) recommends considering normal menstrual return as a cause of postpartum bleeding, which can occur by 6-8 weeks postpartum in non-breastfeeding women 3

The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend obtaining a focused history for delivery mode and complications, as cesarean increases risk of scar complications and endometritis 1
The World Health Organization (WHO) suggests that breastfeeding status affects timing of menstrual return 3
The American College of Radiology recommends assessing quantity and character of bleeding, as pink bleeding suggests lighter flow; heavy bleeding with clots suggests RPOC or vascular abnormality 1
The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines indicate that associated symptoms, such as severe pain, suggest RPOC or scar complications; fever/foul discharge indicates endometritis 1

The American College of Radiology recommends transvaginal ultrasound as the primary diagnostic tool for evaluating postpartum vaginal bleeding, with a sensitivity of 90-95% for detecting RPOC 1
The Society of Radiologists in Ultrasound suggests that color Doppler identifies vascular RPOC requiring intervention and can detect pseudoaneurysms (hypoechoic masses with turbulent flow) 1

The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend obtaining transvaginal ultrasound with Doppler for hemodynamically stable patients with light bleeding, with a specificity of 95-98% for ruling out RPOC 1
The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines indicate that if normal findings are present, likely normal menstrual return; counsel that postpartum menstrual patterns may differ from pre-pregnancy 1
The American College of Radiology recommends considering ultrasound-guided gentle suction curettage if RPOC is identified without significant vascularity, with a success rate of 80-90% 1

The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend never performing blind digital examination before excluding vascular abnormalities or low-lying placenta with imaging, due to the risk of perforation or bleeding 1
The Society of Radiologists in Ultrasound suggests avoiding aggressive sharp curettage that could perforate the thinned cesarean scar if RPOC removal is needed, due to the risk of complications 1

The Centers for Disease Control and Prevention (CDC) recommends reassuring and counseling on contraception if normal menstrual return is diagnosed, as fertility returns rapidly 3, 1
The American College of Obstetricians and Gynecologists (ACOG) guidelines indicate that if RPOC is treated, maintain close monitoring for 24-48 hours with serial hemoglobin checks and watch for delayed complications 1

The American College of Radiology recommends transvaginal ultrasound with color Doppler as the primary diagnostic tool for detecting retained products of conception (RPOC) and uterine artery pseudoaneurysm, with a sensitivity of 90-95% and specificity of 95-98% for RPOC detection 4
The American College of Obstetricians and Gynecologists suggests that CT angiography with IV contrast can be used to localize the bleeding source and identify vascular complications if ultrasound is inconclusive and the patient is hemodynamically stable 4

The American College of Obstetricians and Gynecologists recommends uterine artery embolization (UAE) as the first-line treatment for pseudoaneurysm, with a success rate of >90% for controlling hemorrhage 4
The American College of Obstetricians and Gynecologists suggests that ultrasound-guided gentle suction curettage has an 80-90% success rate for removing RPOC without significant vascularity 4
The American College of Obstetricians and Gynecologists recommends activating a massive transfusion protocol with a 1:1:1 ratio of packed RBCs, FFP, and platelets for massive postpartum hemorrhage (>1500 mL) 5, 6

The American College of Obstetricians and Gynecologists suggests that tranexamic acid 1g IV/PO TID can be used for its antifibrinolytic effect in patients with subinvolution of the placental bed 6
The American College of Obstetricians and Gynecologists recommends misoprostol 600-800 mcg as a medical management alternative for small RPOC 4