Postpartum Bleeding A Minefield! What you see & what to do. - HD

Introduction

I am Dr. Ted Lyons from Winnipeg, Manitoba, Canada.

I'm going to be talking today about postpartum bleeding and focus on some of the things that are of concern and may be difficult in the clinical situations such as retained products or even AV malformations.

I have no commercial associations and most of the photographs have actually been taken myself. I give myself permission to use these.

Late Postpartum Hemorrhage

Late postpartum hemorrhage, either from spontaneous vaginal delivery, therapeutic abortion, or spontaneous abortion.

Is there a normal amount in duration? Yes, there is. There's a gradual decrease in flow and change in color from red to watery pink, and it may last up to two to three weeks, but it's abnormal if anything lasts more than two weeks, postpartum if there's persistent bleeding, or even if there's stop and then start several weeks later, those are all abnormal.

Causes of Postpartum Bleeding

So what are the causes of postpartum bleeding? Continuous bleeding may be due to a failure of the endometrium from which the placenta came, the failure of the endometrium to regenerate or subinvolution.

You can also obviously have retained products in a start and stop re um, situation, endometritis inflammation or an invasive mole gestational trophoblasts disease, and also, AV fistula or AV malformation. But you have to watch out for that. And we'll talk about that later.

Importance of Correct Diagnosis

Why is it important to get the exact cause of the bleeding, correct? Obviously it's important because there are different treatment options with each one.

So delayed endometrial regeneration, you don't do anything. You wouldn't go in and do a DNC on something where there is a normal placental bed, but it just regenerated quickly enough retained product. Obviously with tissue in there, you're gonna want to remove it.

So A DNC endometritis is inflammation and antibiotics are important. An invasive mole, hide it to the form mole needs methotrexate. And finally, the AV fistula or malformation, which may be traumatic or post-traumatic, angiography is very good to assist in the diagnosis and also in the treatment with embolization. Or you may just simply want to watch it.

Bottom line is you've gotta treat the patient, not just the image.

Ultrasound in Unexplained Postpartum Vaginal Bleeding

In unexplained postpartum vaginal bleeding, it's really important to use color and to use spectral to see where there is flow and to track the velocities. Very high velocities are of concern.

Delayed Regeneration of the Endometrium

Delayed regeneration of the endometrium. Here we have a coronal view of a uterus, and there's a spot that I have identified that was where the placenta implanted and there's bleeding from of it.

So it presents with persistent bleeding, probably due to subinvolution, the endometrial bed, the endometrial defect that was the placental bed has not yet re epithelialized and has not gone back to its normal state. So the endometrial and decid Bali have not regenerated the placental site usually, as you would expect.

The ultrasound is negative, you don't see a mass, and there's no increased color velocity. Obviously, conservative therapy, there's nothing to do other than to wait and see. Obviously, A-D-D-N-C is not, not only not necessary, but would even be counterproductive.

So a typical case might look like this nice normal uterus, anti verted, nice endometrial canal, normal endometrium. And the myometrium.

Retained Products of Conception

Retained products of conception. It usually presents with persistent bleeding. And here I've drawn a retained co leadin from the placenta.

Well, in a complete abortion, clinically there is no bleeding ultrasound, no mass endometrial fluid or increased vascularity, and the uterus is non-tender. So here's a nice case of a complete abortion. She did have a gestational sac at six weeks. Now it's all gone. Now there's normal vascularity, so there's no retained products.

But how would that compare to a situation where there is retained product? So here's a patient who is bleeding at 11 weeks menstrual age. She's passing clots. You look in the endometrial canal and there's normal vascularity. So it's a thin stripe. No significant increased vascularity, empty uterus, no increased vessels.

Again, another complete abortion from a early pregnancy that we had seen two weeks prior. A nice normal eight week pregnancy that aborted spontaneously.

So in retained products, what are the findings? Well, clinically they have, they almost always have bleeding, and they may well be passing some tissue. The ultrasound examination within the endometrial canal, you can have a wide endometrial stripe, you can have a mass, or you may see nothing at all color and spectral is critical.

You may see a single or a group of vessels and usually have high velocity flow. It can actually be very striking how high the flow velocity is. And it may be, it may generate a lot of concern, but remember, it's usually a normal finding to have high velocity flow in retained products.

The uterus is non-tender. On pelvic examination, we always look for tender uterus or tender a nexa. That might give us a clue to what the actual patient's problem is. Not everybody does this, but I think it's very, very important in cases with endometritis pain. And a tender uterus is very, very important.

So if you have retained products and you also have some infection that can happen. You have vaginal bleeding that may be persistent. You often have an echogenic mass in the canal, remember, it can be retained products or it can just simply be a hematoma. And they may be difficult to differentiate, although the hematoma will not have any internal vascularity, you will have focal increased vascularity in retained products, obviously, but not in hematoma.

If there is infection as well. Pain and tenderness will give you the indication of endometritis. If you don't push on the uterus and ask the question, does this hurt, then patients will not be able to tell you that it's tender and you will miss the diagnosis of a associated endometritis. So it's very important to ask the question, does this hurt when you're pushing on the uterus or the adexo?

So here's a case, a patient who has bleeding. You can see there in the central endometrial canal, a mass measuring about 17 millimeters in diameter with increased vascularity. The uterus was non-tender. So you have bleeding, you have a mass, you have vascularity in a non-tender uterus.

This woman was three weeks postpartum passing clots. She has retained products, and the treatment is a DNC, a woman who had a therapeutic abortion at five weeks menstrual age, gushing blood has this large echogenic mass identified by the arrows. She had retained products at pathology. And you can see on the color doppler that there's tremendous increased vascularity in that mass.

So the mass, the increased vascularity and the clinical situation of a patient who is bleeding following a therapeutic abortion are all indicative of retained products. And that's what it was.

I mentioned this specifically because many centers use just 2D ultrasound and don't always use endo vaginal. And endo vaginal is critically important, but also is color and also is identifying focal areas of tenderness.

Another patient, three weeks after a spontaneous vaginal delivery had an area of increased echogenicity, tremendous increased vascularity. So obviously we're thinking about retained products. And here on a video, you can see the area of increased vascularity in the fundus, an area that is common to have retained products. And when you do the spectral, you can see high velocity flow over a hundred centimeters per second and even up to 160 centimeters per second.

So, retained products, A woman who had a therapeutic abortion six weeks ago, continuous bleeding, does she have retained products? You look at this scan and you say, I'm not sure if there's anything going on, but look carefully. There is an area of increased echogenicity in the myometrium anteriorly, and there was increased vascularity and high velocity flow.

So whereas the 2D image was perhaps a little bit subtle, the color turns you on to the fact that she has retained products. And in fact, at DNC, they had retained products.

So retained products has a variety of appearances. Here's another patient. 30 weeks. She had, she's four weeks postpartum, post cesarean section with bleeding and a very subtle mass. So here you see this beautiful, triangular shaped defect, typical of a previous cesarean section. You may not have really appreciated this echogenic mass up in the fundus. Here it is highlighted, but that echogenic mass was retained product.

You turn on color, you have an area of increased echogenicity. And at DNC, this was retained product. So she had a mass pain, a mass bleeding, and vascular increased vascularity.

Sometimes it's very difficult. This 30 5-year-old woman has been bleeding for two weeks after a spontaneous abortion at 19 weeks. Does she have retained products? That's usually the question that they ask. Does she have retained products? You look at that and the uterus is certainly bulky. The endometrial canal looks empty. But what about this area? It is heterogeneous. Is this an area of retained products?

She actually had an area of increased vascularity, right in that subtle area. So we suspected that she did have some retained products. There, again, more based on the area of increased vascularity. And this in fact at DNC was proven to be retained product.

So there's a wide variety of appearances of retained products. Here's a patient who had a therapeutic abortion 26, six weeks ago. She had at the time a five centimeter corpus lutetium cyst, and it was felt to be useful to follow up the cyst. She's on day five of a rather heavier than normal period. Other than that, she's had no symptoms.

Sono graphically on sagittal view, you see nice endometrial canal, transverse view, similar nice endometrial canal, nice myometrium, nothing really exciting, but you turn on the collar. And here you see again an area of increased vascularity extending down to the endometrial canal. And there was some increased vascularity.

So this patient actually had a DNC and had a small area of retained products. I suspect this is far more common than we actually see small areas of retained products. And is treatment always necessary or will these actually resolve spontaneously?

So to treat or not to treat, that's the question. Most gynecologists treat the symptoms. You don't treat the images, you treat the patient, you treat the symptoms. If there are ultrasound findings of retained products, but no bleeding, do you watch and wait? Most will, except if there is a large mass and signs of myometrial invasion. And that should be monitored closely on ultrasound. And obviously if you have tenderness, signs of infection, uterine tenderness, they're gonna want to give antibiotics.

You're never gonna know if that uterus is tender unless you say the words while you're pushing on the uterus. Does this hurt? Is it tender? Here's a wonderful example. 30 5-year-old girl at 15 weeks, bleeding. Is this an incomplete abortion? Is there retained products after an abortion?

She has an area of increased, a um, an area increased in, no, she has tissue or she has echogenic material within the endometrial canal that has no vascularity. So is this an incomplete abortion with products of conception in the lower uterine segment, or could this just simply be a blood clot? Again, treat the patient. She was bleeding. They did a DNC.

This is a very interesting patient. She was absolutely asymptomatic. Three and a half months postpartum, maybe she had a little bit of spotting or else she wouldn't have come to ultrasound. We saw this large mass, echogenic mass with no increased vascularity, situated right in the endometrial canal.

When I called the doctor and I said, there's something going on in there, she was absolutely amazed. She said, are you sure? Because this woman is absolutely asymptomatic. No, I said, there's definitely tissue there. She said, well, okay. They did a DNC, and there was retained products, most unusual in a woman with very, very little symptoms for such a large mass lesion.

She had, again, the mass, but really very little bleeding, not a lot of increased vascularity and non-tender, but she did have retained products.

Another patient, nine weeks post cesarean section with bleeding passed clots two days ago. Well, you do the scan. Endometrial canal is not bad. No real increased vascularity. So it looks pretty normal. And in this patient, you may well want to just simply again, treat the patient. She's not having a lot of symptoms other than some bleeding. She may well be treated and was treated conservatively.

A 29-year-old patient, 12 weeks, but no bleeding. She has past clots, but there's no bleeding right now. She has a wide endometrial stripe and some increased vascularity. She was pregnant. Here is a five week pregnancy. She had a therapeutic abortion. And the question is, what do you do?

Well, sorry, this was her again with a large empty gestational sac. So on the sequence of events, she had an early pregnancy with the large jokes act. Now she has a failed intrauterine pregnancy, and so you're gonna want to monitor it. She actually passed the sac. Here is where the implantation was, where that increased vascularity. And here you see that area of retained products is where the implantation site was originally. So there's good correlation. She had retained products.

She doesn't have any bleeding now. So how are you gonna actually treat this patient? I think that this, and here you can see the vascularity on the cine. You can see the increased vascularity on the posterior wall, which was the site of the retained products.

The this particular patient, they watched her, she had no clots in the last seven days. The endometrial stripe is now thinner. The question is, was there any increased vascularity? And in fact, there was some persistent increased muscularity And she had some retained products. No mass, just the vessel only, one week later, no vessel.

So was this really increase? Was this really retained products or can you just see a persistent vessel that may in fact resolve on its own? And do you always need treatment?

So regardless of what the ultrasound may show, you gotta treat the patient. And so she had conservative treatment with resolution.

Two weeks later, another patient, 12 weeks, menstrual age, bleeding past a fetus. Does she have retained product? So she has a widened endometrial stripe with no increased vascularity. She had a DNC the next day they had decidua only, but no evidence of retained products. So she had the DNC because she was bleeding, but we didn't see any increased vascularity.

Here, A woman who was 22 years old, had a therapeutic abortion at nine weeks, some bleeding that has now decreasing. So does she have any retained products? So she has a widened endometrial stripe. She has some echogenic material, no increased vascularity. How are you actually gonna treat this patient? She has no bleeding. She has maybe a little bit of a mass and no vascularity. And so you may well want to treat this patient conservatively.

Retained Products and Endometritis

Retained products and endometritis, you have to do an endo vaginal exam in order to assess uterine tenders. And you have to ask the patient, does this hurt?

So here's a patient, two weeks postpartum. She has pain and bleeding. So here on ultrasound, you can see the echogenic mass. You can see all kinds of increased vascularity. And she has a tender uterus. She has little bits of air in the endometrial canal that you may or may not see, but the uterus was tender.

So she has retained placenta retained products, and she has endometritis. And here, And then following A DNC, she had a DNC and following a DNC, she had that mass removed, with only a small amount of fluid in the endometrial canal.

Endometritis

Endometritis with retained products or without retained products. Four days post therapeutic abortion fever and increased white count. Obviously, if patients have all of the clinical signs of infection, maybe they're passing some foul smelling fluid, they have a fever, they have increased white count. There's no question that they have an infection somewhere. And if they've had a recent instrumentation in the uterus, that's the area that you're gonna look at.

And she has retained products and she has a tender uterus. Here you can see tender. She has a tender uterus. So she has retained products as well as endometritis.

A 20-year-old who had a therapeutic abortion five weeks ago. She's bleeding despite antibiotics. Some physicians, if a woman comes in following a therapeutic abortion and has very minimal symptoms, but has some uterine tenderness, and you can see the uterus was tender on ultrasound, they may just give them antibiotics in the office and not in fact do an ultrasound examination.

So here they did the ultrasound. Is there any abnormality? Well, there may be a small area of increased tissue with some increased vascularity. This could be a small area of retained products, but a tender uterus. So she had a DNC to remove this area of retained products, and she had antibiotics to cover the infection.

Metritis only may appear with spotting or bleeding weeks after delivery. The scan is often done to rule out retained products. They have may, may have minimal discharge or minimal fever. Ultrasound findings may be normal. There may be some endometrial fluid, maybe some air occasionally, and uterine tenderness on endo vaginal examination. And obviously the treatment for endometritis only is antibiotics and not a DNC.

Here's a patient who had a therapeutic abortion at 16 weeks. Five weeks later, she's got some bleeding fever, foul smelling discharge, no history of pelvic inflammatory disease. The uterus looks fine, no retained products, but the uterus was tender to palpation. She has endometritis and she would be treated with antibiotics only.

A patient three weeks postpartum, recurrent fever pain, manual removal of the placenta, that's a key. Someone put their hand in there in order to treat the patient at the time for a placenta that was overly adherent. So they may well introduce infection within to the uterus. She has some free fluid in the endometrial canal, echogenic areas consistent with air. So she had, and a tender uterus. So she had retained products.

Here's a patient five days after a cesarean section has fever. So obviously there's some infection somewhere. This is a view of the lower uterine segment. Here we're looking at the cesarean section scar, but it actually has a hematoma within it. It has a mass, and it has areas of increased echogenicity consistent with air. So she has an infected cesarean section hematoma.

AV Fistulas and Malformations

Another patient, and this is a real dilemma. This is a patient who has she had a therapeutic abortion, and now she comes back with some bleeding. You see areas of significant increased vascularity with high velocity flow. And the question is, is this just simply retained products?

So high velocity vascularity retained products is very common. Remember, there are AV fistulas within this placental adherent placental tissue. So they're common in retained products. You can successfully treat it with the DNC and seldom have excess blood loss.

But when you're looking at the myometrium, one of the things that you should look at, it's not always there, but one of the things you should look at is are there any large myometrial holes that may have high or even low velocity flow? A large AV fistula, and this is different than retained products because there's a tremendous amount of flow, has usually large holes in the myometrium, large vessels and excess bleeding. And in fact, one of the concerns is that they can exsanguinate.

So causes of bleeding, AV fistula or malformation, remember, it can still be retained products, gestational trophoblastic disease. What is the difference with an AV fistula? People will bleed, like stink, your gushing blood. The beta may well be negative, high velocity flow, large holes in the myometrium and treatment. You may have to do compression with an intrauterine catheter. You may want to embolize or you then may wanna wait and some of these people may actually require hysterectomy.

With gestational trophoblastic disease or a mole, you have moderate bleeding. The beta eight CG is gonna be positive. The vascularity that you see has low velocity rather than high velocity. You may actually have large holes in the myometrium and a mass of vessels, but you're gonna treat it mostly with methotrexate. You may also require a DNC.

So here you have a patient bleeding six weeks after a therapeutic abortion. Question was, was the retained products. Here you can see a mass of tissue In this particular patient, an article had recently come out about AV fistulas. And so we were keen on looking at the vascularity, and you can see these corkscrew vessels, high velocity flow. We were concerned that this patient actually may have an AV fistula, not just retain product.

So we talked the radiologist into doing an angiogram, and they saw areas of rapid filling of venous flow as well as arterial flow. And they said, yes, there are some, there is some AV fistulas there. The seasoned an grapher said, no, she's a young girl. I'm not gonna do any embolization. I'd have to embolize too much, and I don't want to affect her potential fertility. So he did nothing.

I wondered what became of that woman, and six months later I called her back for repeat ultrasound. I said, whatever happened after you had the angiography? She said, well, nobody treated me. The bleeding stopped. And six months later, obviously she had nothing serious, and now she's pregnant again.

So obviously, so it's clear that what the seasoned angiography did is just give this woman a tincture of time, watch her conservative treated conservatively, and not do any angiography, was the right treatment.

So now you look at a patient who has huge volume and extent of flow. 26 years old, it's had numerous pregnancies, and now you see a uterus that has these big holes in it. It looks abnormal, these big myometrial holes and some fluid in the endometrial canal, whatever it is, this can't be normal.

So this we were really quite concerned about. We brought her, we turned on the color and here she has flow, extensive flow throughout these myometrium. This is definitely abnormal. And she did have increased flow, so the flow was not that high, but it was definitely abnormal for sure.

So now what are we gonna do? Here in power doppler again shows the massive amount of flow in the uterus. So she needs an angiogram and they did an angiogram on her. Then you can see that as soon as they put contrast into the left uterine artery, she's almost immediately getting huge amount of venous flow.

So she's got a large AV fistula in that uterus, and that's what's causing all of the ultrasound findings. They also had increased flow in the ovarian artery as well. So what they then did was here you can see the right ovarian artery that also has significant increased flow.

So this patient needs surgery, post angiography, they embolize the uterine and right ovarian arteries in order to control the flow prior to surgery. And here you can see some of the coils that were put in. They then took her to surgery.

So here you can see the uterus and the right ovary, the enlarged right ovary. Here you can see the uterus and the left ovary and the large right ovary, normal left ovary and enlarged right ovary. They remove the uterus uneventfully and the uterus looks not too bad when you open it up, you can see these large vessels that obviously because the pressure from the arterial system has been removed, the vessels are much less dramatic.

But this patient had AV fistulas that would have, that could have been disastrous for her.

Another patient she delivered at 21 weeks manual removal of the placenta. And she has, again, tremendous area of increased vascularity and sort of small holes in the myometrium. Is this an AV fistula? Is this something that we have to be really concerned about? She had tremendous amount of vascularity seen associated with this with these holes and with the mass in the endometrial canal.

So she had large vessels, increased velocity. What are you gonna do? Does she also need a hysterectomy? She's only 22 years old and she's just delivered a baby. Well, the patient went to the ward after ultrasound, she had uncontrollable bleeding. So now you're wondering about AV fistula. The interventional radiologist would not embolize. And so the obstetrician put in an intrauterine balloon, really just a Foley catheter.

The balloon stopped the bleeding compression. It stopped the bleeding and 24 hours later it was removed. She had no bleeding and she was sent home two weeks after what looked like a disastrous situation. Uterus looks normal. So they had compressed and stopped the massive amount of flow in this woman. And so just with conservative management and balloon compression, she actually retained her uterus and everything was fine.

So av fistulas versus retained products. Don't over call AV fistulas 'cause the results can be disastrous. AV fistulas should have large myometrial holes, but not always. And there's a large overlap between av fistulas and retained products of conception.

Here is a patient five weeks postpartum, had heavy bleeding and clots. Again, is this retained product or AV fistula? She decided just simply to leave home the hospital. She did have some increased vascularity, but we're seeing a lot of things that it's not absolutely always clear. She had an area of increased vascularity. She left and she came back fine.

So was this retained product or was this just simply could this have been an AV fistula?

Now here's an area that's much more concerned in large uterus, thickened myometrium, a bunch of holes in a woman who has a high beta HCG, high beta HCG. So now we're not thinking of retained products, but what we should be thinking of high form mole. And here, when you look at the vascularity, it's low vascularity. So high beta HCG, low vascularity, we're thinking now, hi deform mole. And that's in fact what it was.

You look at this and it looks well, there's a mass and increased vascularity. And a woman who had a therapeutic abortion six weeks ago has been bleeding for six weeks, has a positive beta. I might just simply have called this retained products had it not been for the positive beta. But remember, the beta can continue to be positive after delivery and gradually dropping. Hers was not dropping the mass, the low velocity flow. She actually also had an invasive mole. It looks different than the previous case.

So again, there's a wide variety of these trophoblastic, invasion of the myometrium. What's the significance? May need surgery, but can resolve spontaneously.

A woman with bleeding six weeks post spontaneous vaginal delivery, manual removal of the placenta. You look and you see a big mass there. You have to look closely because the mass seems to extend into the myometrium. And when you look closely there, it is going almost to the serosal surface. So the question is, is this retained products? And but more importantly, is there an area of placenta in Creta.

When you look back at the seven week scan, you can see that the placenta was extending right into the myometrium. She has an area of placenta and creta. She had had enough pregnancies they were quite concerned about her and they decided to do a hysterectomy.

Here's the un bisected uterus. And here you can see the bisected uterus with that trophoblastic sending right out to the serosal surface. So this was a mass of invasive trophoblastic tissue. Obviously a hysterectomy was the correct case, was the correct treatment in this case.

Another patient early pregnancy failure, 29 weeks untreated myometrial invasion. So here we look at this case and we see the non-grain uterus here. Then she gets pregnant. It looks not too bad. You can see the gestational sac. She's had some bleeding at eight weeks. She doesn't want a DNC, so we're managing it. Expectantly, normal placental implantation site anteriorly.

We keep following her now a week later, and she has a prominent vessel extending right into the myometrium. And you can see it on 3D prominent vascularity in the anterior myometrium. So what is this? Is this retained products? And she has, again, high velocity flow, and is there anything we need to do about it?

Well, if you look again at the 2D, you can see this heterogeneous trophoblast extending into the myometrium. Does this patient need a hysterectomy? This was one week apart. She has persistent trophoblast with increased vascularity, but she's clinically well. So what to do next? Do you monitor her beta? We should monitor her beta. Do you do a DNC or do you give methotrexate?

Well, they decided to give methotrexate, and a week later everything is cleared up. So sometimes, and here it looks quite normal. So sometimes just simply watching, we're seeing a lot of things that we weren't seeing before because of the improved equipment. But do you always have to treat the things that you're seeing?

Patient who has 10 weeks early pregnancy failure, an empty gestational sac, and you look at the endometrial canal and extending into the myometrium is an area of increased echogenicity. It looks like myometrial invasion. There's some increased vascularity in that region. What should you do? Is this molar invasion? Is this trophoblastic invasion? There was some high velocity flow. She's only spotting. So what do you do?

Well, this patient they just simply, again, they treated conservatively and she resolved At 16 weeks pregnant. This woman has had bleeding for two months and finally just came to see a doctor. She has these big holes in the endometrium or my very, very confusing, and some has some high velocity flow.

We brought her back a day later because I wasn't, or two days later, I wasn't exactly sure what was going on, sorry, three days later. And she had passed whatever it was. And I said, well, it must have been a mole. Did you pass a bunch of grapes? She said, no, no. She said, I passed a collapsed fetus.

So this whole area that is quite distorted maybe that was the head and the body. I don't know. But this was actually a collapsed fetus.

Finally, here you have a patient, again, a similar situation. She had some interventional procedure. Now she's got this big mass in the endometrial canal, but it's avascular. Remember, an avascular mask can simply be a hematoma. She was pregnant earlier. She had a small embryo. She had a therapeutic abortion. And now she has a hemato omera, a omera, no mass. And in fact, depending on her clinical situation, you may do a DNC, another patient with a clot, a vascular clot in the endometrial canal, mixed echogenicity, hemato omera, or a blood clot rather than retained products. And the only way you're gonna know is by looking at vascularity.

Conclusion

So late postpartum bleeding. First of all, it requires a good history. Is this continuous versus stop and start bleeding is the uterus tender? The only way you're gonna know about uterine tenderness is talk to the patient. When you're scanning with an endo vaginal probe and you're touching the uterus, you've gotta ask the question, is that, does that hurt? Is the uterus tender?

Endo vaginal ultrasound is absolutely critical. And remember, use color and use spectral. So examine the uterus, push on it, ask if it's tender. Use color always to see if there's increased vascularity, and use spectral to see whether or not this is high velocity flow.

Thank you very much. I hope that this talk has been useful for you.