A 26-year-old woman, gravida 2 para 2, comes to the emergency department due to increased vaginal bleeding and abdominal cramping. A week ago, the patient underwent a prolonged induction of labor for gestational diabetes mellitus that was complicated by an intraamniotic infection treated with intravenous antibiotics. She had a vaginal delivery of a 4.7-kg (10.4-lb) male infant and was discharged from the hospital on postpartum day 3. The patient was doing well until this morning, when she started to bleed through a sanitary pad every hour and began to have increasing abdominal cramping. Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 98/min. The uterus is firm, palpable at 6 cm above the pubic symphysis, and nontender to palpation. On speculum examination, there is active bleeding from the cervical os with passage of large clots. Which of the following is the most likely diagnosis for this patient?

Question

A 26-year-old woman, gravida 2 para 2, comes to the emergency department due to increased vaginal bleeding and abdominal cramping.  A week ago, the patient underwent a prolonged induction of labor for gestational diabetes mellitus that was complicated by an intraamniotic infection treated with intravenous antibiotics.  She had a vaginal delivery of a 4.7-kg (10.4-lb) male infant and was discharged from the hospital on postpartum day 3.  The patient was doing well until this morning, when she started to bleed through a sanitary pad every hour and began to have increasing abdominal cramping.  Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 98/min.  The uterus is firm, palpable at 6 cm above the pubic symphysis, and nontender to palpation.  On speculum examination, there is active bleeding from the cervical os with passage of large clots.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_da68_2d4b_bc81_bd623143d48f_MD0003_00 This patient with heavy vaginal bleeding (eg, saturating ≥1 pad/hr, passage of large clots) >24 hours after delivery has a secondary (late) postpartum hemorrhage (PPH). Risk factors for secondary PPH are similar to immediate-onset PPH and include prolonged labor, fetal macrosomia, and intraamniotic infection (all of which are seen in this patient). Common causes are retained products of conception, postpartum endometritis, and inadequate placental site involution (ie, subinvolution). In this patient, the most likely cause of secondary PPH is retained products of conception from her prior intraamniotic infection and prolonged induction of labor. Patients with an intraamniotic infection are at risk for retained products of conception, even if the infection is adequately treated, because the intrauterine inflammation allows for adherence of the placental membranes to the uterine wall. In contrast to a retained placenta, which causes immediate PPH with uterine atony (eg, boggy, enlarged uterus), retained products of conception typically cause late PPH with either a boggy or firm uterus (as in this patient). Evaluation is with pelvic ultrasound (which can identify the location of the retained products), and treatment is typically dilation and curettage. (Choice A) Cervical laceration, often caused by trauma associated with operative vaginal delivery or fetal macrosomia (ie, >4 kg), typically causes an immediate, not late, PPH. In addition, this patient's bleeding is from the cervical os rather than the cervix itself. (Choice B) After delivery, lochia can continue up to 6 weeks postpartum. Patients 1 week postpartum typically have lochia rubra (bright red blood, small clots) or lochia serosa (serosanguineous discharge) that soaks <1 pad/hour. This patient's sudden onset of heavy bleeding makes a secondary PPH more likely. (Choice C) Postpartum endometritis is a common cause of secondary PPH and is more likely to develop in patients who had an intraamniotic infection (such as this patient). However, this patient has no fever or uterine tenderness, making this diagnosis unlikely. (Choice E) Uterine rupture can cause late PPH in patients with prior cesarean delivery and typically presents with severe uterine tenderness and abdominal pain (due to hemoperitoneum). Educational objective: Secondary (late) postpartum hemorrhage is heavy vaginal bleeding occurring >24 hours after delivery. Common causes include retained products of conception, postpartum endometritis, and placental site subinvolution. References: Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. (http://www.ncbi.nlm.nih.gov/pubmed/29052024) Recurrent secondary postpartum hemorrhages due to placental site vessel subinvolution and local uterine tissue coagulopathy. (http://www.ncbi.nlm.nih.gov/pubmed/24558972)

A 26-Year-Old Woman, Gravida 2 Para 2, Comes to the Emergency