A 27-year-old woman, gravida 1 para 1, comes to the office for evaluation of postpartum bleeding. Four days ago, the patient had a forceps-assisted vaginal delivery due to recurrent fetal decelerations. She had a third-degree perineal laceration that was repaired, and she went home on the second postpartum day. Since delivery, the patient has had continuous, dark red vaginal bleeding with small clots, requiring her to change a menstrual pad 6 to 7 times daily. She has no chest pain, shortness of breath, or orthostasis. Temperature is 99.5 F (37.5 C), blood pressure is 124/76 mm Hg, and pulse is 88/min. BMI is 33 kg/m². The uterine fundus is firm, nontender, and palpable at 4 cm below the umbilicus. The perineal laceration repair is intact, and the cervix is 1 cm dilated with minimal dark red blood in the vagina. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_da52_824a_bc81_0b2085c73004_MD0003_00 After delivery, the uterus contracts, becoming smaller and compressing the placental bed vessels to protect against immediate postpartum hemorrhage. In the following days to weeks postpartum, uterine involution continues and a slow process of endometrial shedding and regeneration takes place, resulting in physiologic vaginal bleeding known as lochia. Lochia typically transitions from red/brown bleeding with small clots (lochia rubra, days 0-4 postpartum), to light serosanguinous bleeding (lochia serosa, days 4-14), and finally to white discharge (lochia alba). Patients often have concerns about postpartum bleeding because it is heavier and more prolonged than normal menses. These patients should be evaluated for features concerning for delayed postpartum hemorrhage, including the following: Passage of large blood clots Increased pad counts (eg, saturation of ≥1 pad/hr for ≥2 consecutive hours) Signs and symptoms of anemia (eg, dizziness, chest pain) due to acute blood loss In contrast, this patient with passage of small clots, normal vital signs, a benign examination (eg, firm uterus, intact perineal repair), and an appropriate postpartum hemoglobin level likely has normal lochia. Therefore, the best next step in management is observation and reassurance that this bleeding is normal and may last for up to 6 to 8 weeks postpartum. (Choice A) Broad-spectrum antibiotics are administered for postpartum endometritis, which can present with heavy lochia but typically causes fever, malodorous vaginal discharge, and uterine tenderness, which are not seen in this patient. (Choice B) Dilation and curettage is indicated for postpartum hemorrhage due to retained placenta or membranes. These patients typically have a soft, boggy uterus (ie, atony). This patient's uterine fundus is firm, making this diagnosis less likely. (Choice D) Postpartum quantitative β-hCG levels are used to evaluate for gestational trophoblastic neoplasia, which typically presents with heavy uterine bleeding several weeks after a molar pregnancy. β-hCG levels are not measured immediately after a normal delivery because they typically take weeks to return to normal. (Choice E) Reduced von Willebrand factor activity (ie, von Willebrand disease) can cause delayed postpartum hemorrhage due to impaired platelet-endothelial binding and reduced factor VIII levels. This patient has no signs of delayed postpartum hemorrhage (eg, large blood clots, increased pad counts, symptomatic anemia). Educational objective: Lochia is physiologic vaginal bleeding after delivery due to endometrial shedding and regeneration. It can last up to 6 to 8 weeks postpartum. References: Puerperal loss (lochia) in women with or without inherited bleeding disorders. (http://www.ncbi.nlm.nih.gov/pubmed/20417483) Lochia patterns among normal women: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23101487)

A 27-Year-Old Woman, Gravida 1 Para 1, Comes to the Office