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Hemorragia posparto secundaria (tardía)

Autores: Michael A. Belfort, MBBCH, MD, PhD, DA (SA), FRCSC, FRCOG, FACOG, Thierry AGM Huisman, MD, PD,
FICIS, FACR
Editores de sección: Lynn L. Simpson, MD, Dra. Deborah Levine
Redactor adjunto: Vanessa A Barss, MD, FACOG

Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .

Revisión de la literatura actual hasta:  octubre de 2022. | Última actualización de este tema:  19 de octubre
de 2022.

INTRODUCCIÓN

La hemorragia posparto (HPP) puede ocurrir poco después del nacimiento (hemorragia
posparto primaria, dentro de las primeras 24 horas) o, con menos frecuencia, días o
semanas después. Este tema tratará la HPP secundaria (también llamada tardía). Los
problemas relacionados con la HPP primaria se revisan por separado:

● (Consulte "Resumen de la hemorragia posparto" .)

● (Consulte "Hemorragia posparto: manejo médico y mínimamente invasivo" .)
● (Consulte "Hemorragia posparto: enfoques de manejo que requieren laparotomía" .)

DEFINICIÓN/DIAGNÓSTICO

La HPP secundaria generalmente se define como cualquier sangrado uterino significativo

que ocurre entre las 24 horas y las 12 semanas posteriores al parto [ 1,2 ]. Sin embargo, las
definiciones varían (p. ej., entre 48 horas y 6 semanas después del parto).

INCIDENCIA

La HPP secundaria ocurre en 0,2 a 2,5 por ciento de las pacientes posparto en países de
altos ingresos [ 2-6 ]. La mayoría de los estudios informan que la incidencia máxima es de
una a dos semanas después del parto [ 2 ]. Los datos para los países de bajos ingresos no
están disponibles.
ETIOLOGÍA

Las causas más comunes de HPP secundaria son [ 2 ]:

● Productos retenidos de la concepción (RPOC), incluida la placenta accreta focal

● Subinvolución del lecho placentario
● Infección

Las causas menos comunes y raras incluyen [ 2,7-20 ]:

● Diátesis hemorrágica hereditaria o adquirida, incluidos los medicamentos que pueden

predisponer al sangrado
● Pseudoaneurisma de la arteria uterina, arteria pudenda interna, arteria vaginal o
arteria labial vulvar
● Malformación arteriovenosa (MAV)
● coriocarcinoma
● Carcinoma de cuello uterino no diagnosticado
● adenomiosis
● Pólipo infectado o fibroma submucoso
● divertículo uterino
● Sangrado excesivo con reanudación de la menstruación
● Hipoestrogenismo
● Dehiscencia de cicatriz de cesárea

A veces no se puede determinar la causa.

FACTORES DE RIESGO

Una historia previa de HPP secundaria parece predisponer al paciente a una recurrencia
(odds ratio [OR] 6,0, IC del 95 %: 2,1-16,8 [ 21 ]) [ 21-23 ]. Una historia de HPP primaria es un
factor de riesgo de HPP secundaria grave (OR 4,7, IC del 95 %: 1,9-11,6 [ 21 ]) [ 4,21,24 ].

Los factores de riesgo para la retención de productos de la concepción (RPOC), la

subinvolución del lecho placentario y la infección incluyen anomalías placentarias, trabajo de
parto prolongado y la necesidad de extraer manualmente la placenta. (Consulte "Retención
de placenta después del parto vaginal" y "Endometritis posparto" y "Descripción general de
la hemorragia posparto", sección sobre "Factores de riesgo de HPP" .)

PRESENTACIÓN CLÍNICA
El sangrado vaginal en exceso de lo esperado es el síntoma de presentación. El sangrado
puede ir acompañado de dolor pélvico, fiebre, sensibilidad uterina y/o recuento elevado de
glóbulos blancos. Estos hallazgos clínicos son inespecíficos; además, es normal tener algo de
sangrado posparto, un recuento de glóbulos blancos levemente elevado y/o molestias leves.
(Consulte "Descripción general del período posparto: fisiología normal y atención materna
de rutina", sección sobre 'Involución uterina' ).

PACIENTES HEMODINÁMICAMENTE INESTABLES

Para el paciente que tiene sangrado abundante y es hemodinámicamente inestable, la

estabilización con líquidos y transfusión de hemoderivados es la prioridad, seguida de una
evaluación diagnóstica. Nuestro enfoque se describe en el algoritmo ( algoritmo 1 ).

En pacientes que experimentan HPP secundaria en las primeras semanas después del parto,
la cavidad uterina puede ser lo suficientemente grande para admitir un dispositivo de
taponamiento con balón, que puede ser útil para limitar el sangrado mientras se realiza la
evaluación diagnóstica. Si el fondo uterino no es palpable abdominalmente, entonces la
cavidad uterina es probablemente demasiado pequeña para acomodar un dispositivo de
taponamiento uterino comercial, pero aún puede ser posible colocar un catéter vesical
estándar con un globo de 10 a 30 ml en la cavidad uterina y usar este globo para
taponamiento. Si ninguna de estas intervenciones es posible, el taponamiento del útero con
gasas puede limitar la hemorragia mientras se traslada a la paciente al lugar adecuado para
el tratamiento definitivo. (Consulte "Hemorragia posparto: uso de taponamiento
intrauterino para controlar el sangrado" .)

Si el paciente no se puede estabilizar rápidamente, es importante trasladarlo a un lugar

adecuado para una intervención quirúrgica de emergencia (quirófano o sala híbrida de
radiología intervencionista/quirúrgica) donde se pueda realizar un examen bajo anestesia y
procedimientos quirúrgicos para controlar la hemorragia. Si el sangrado se controla con
taponamiento y el paciente está estable, se puede realizar una evaluación adicional de las
causas en un lugar no quirúrgico (p. ej., departamento de emergencias o sala de ultrasonido
para examen ecográfico, o sala de radiología intervencionista). En las últimas décadas, la
radiología intervencionista ha demostrado ser una opción de tratamiento alternativa valiosa,
no quirúrgica, mínimamente invasiva, eficaz y segura para controlar las hemorragias
uterinas potencialmente mortales. La angiografía por catéter tiene una doble función:25-29
]. (Consulte "Hemorragia posparto: enfoques de manejo que requieren laparotomía" .)

EVALUACIÓN DIAGNÓSTICA

Historia y examen físico

● ¿Cuál es la historia obstétrica pasada (incluido el nacimiento reciente)? Si el paciente
tuvo una HPP previa, la HPP recurrente puede tener la misma etiología. ¿El embarazo
más reciente tuvo factores de riesgo de retención de productos de la concepción
(RPOC, p. ej., parto prematuro, gestación múltiple, retención de placenta) o
endometritis posparto? (Consulte "Endometritis posparto", sección "Factores de riesgo"
.)

¿Cuál fue la vía de nacimiento? Los RPOC son mucho más probables después del parto
vaginal que el parto por cesárea, mientras que la endometritis posparto es más
probable después del parto por cesárea. Sin embargo, el RPOC puede ocurrir después
de un parto por cesárea, incluso cuando el obstetra cree que se extrajo toda la
placenta. Por lo tanto, el diagnóstico no debe excluirse en función de la historia
quirúrgica.

Las anormalidades vasculares uterinas son raras. Las malformaciones arteriovasculares

adquiridas (MAV) y los seudoaneurismas generalmente se deben a traumatismos (p. ej.,
dilatación y legrado relacionados con el embarazo, traumatismos vaginales y
perineales ocurridos durante un parto vaginal espontáneo o asistido, parto por
cesárea). Cuando se observa un aumento de la vascularización en el miometrio
posparto, casi siempre se debe a una subinvolución del lecho placentario, más que a
una MAV [ 30 ]. (Consulte 'Subinvolución del sitio placentario' a continuación).

● ¿Tiene el paciente factores de riesgo para una diátesis hemorrágica, como la

enfermedad de von Willebrand (VWD)? Un historial de sangrado menstrual abundante
u otro historial personal o familiar de sangrado excesivo o inusual aumenta la
probabilidad de una diátesis hemorrágica. En un estudio de 16 partos de pacientes con
EvW no reconocida, la incidencia de HPP primaria y secundaria fue del 47 y el 31 %,
respectivamente [ 31 ].

El examen de laboratorio básico para una diátesis hemorrágica incluye recuento de

plaquetas, tiempo de protrombina y tiempo de tromboplastina parcial activada; sin
embargo, estas pruebas pueden ser normales en pacientes con VWD. (Consulte
"Abordaje del adulto con sospecha de trastorno hemorrágico", sección "Evaluación de
laboratorio" y "Abordaje del adulto con sospecha de trastorno hemorrágico" .)

● ¿La paciente está tomando algún medicamento (recetado, de venta libre, suplementos
dietéticos o vitaminas) que pueda predisponerla al sangrado uterino, como
anticoagulantes, inhibidores plaquetarios y relajantes uterinos ( tabla 1 )?

● ¿Ha estado expuesta la paciente a alguna toxina industrial u otros venenos (p. ej.,
veneno de serpiente) que puedan haber afectado su estado de coagulación?
 ● ¿Se ha descartado mediante examen una fuente de sangrado vaginal o cervical, en
lugar de uterina? Un parto traumático, el coito o la inserción de un objeto extraño
pueden causar sangrado vaginal o cervical.

● ¿Hay signos o síntomas de infección uterina, como dolor o sensibilidad uterina, fiebre,
taquicardia o flujo vaginal maloliente? Los factores que predisponen a la infección
pueden incluir el sexo vaginal, el uso de un tampón o la inserción de un dispositivo
intrauterino poco después del nacimiento. (Consulte "Endometritis posparto" .)

Pruebas de laboratorio

● Hemograma completo.

● Tiempo de protrombina, tiempo de tromboplastina parcial activada, nivel de

fibrinógeno, tromboelastograma (si está disponible).

● Gonadotropina coriónica humana (hCG): en pacientes con sangrado muchas semanas

después del parto, una prueba de embarazo cuantitativa es útil para evaluar
coriocarcinoma, RPOC o incluso un nuevo embarazo. Es posible que se necesite un
examen de ultrasonido y determinaciones seriadas de hCG para distinguir entre estas
entidades cuando la prueba es positiva. (Consulte 'Administración' a continuación).

Imágenes  :  la modalidad de imágenes de primera línea para la HPP secundaria es la

ecografía transabdominal y, siempre que sea posible, la ecografía transvaginal, incluidas las
técnicas de imágenes anatómicas bidimensionales (2D) y tridimensionales (3D), así como el
Doppler color y espectral. Si los hallazgos de la ecografía son indeterminados, se puede
realizar una tomografía computarizada (TC), incluida una angiografía por TC con contraste
(CTA) y una venografía por TC (CTV), o una resonancia magnética nuclear (RMN), incluida una
angiografía por RM (MRA) y una RM- venografía (MRV), se puede utilizar. La angiografía por
sustracción digital con catéter es una importante herramienta diagnóstica, y posiblemente
terapéutica, para el diagnóstico definitivo de anomalías vasculares uterinas [ 32 ].

En la mayoría de los casos, la ecografía puede identificar la causa del sangrado y ayudará a
reducir el diagnóstico diferencial. La ecografía anatómica 2D y 3D permite la identificación
de lesiones focales dentro del miometrio o dentro de la cavidad endometrial. La ecografía
Doppler color y espectral es muy útil para determinar la vascularización de la anomalía
identificada, lo que permite diferenciar entre un coágulo de sangre (sin flujo), RPOC (puede o
no tener flujo) y otras lesiones vasculares uterinas. La velocidad sistólica máxima debe
determinarse cuando se observa un vaso anormal. Sin embargo, el útero posparto tiene una
apariencia variable en el examen de ultrasonido, y existe una superposición considerable
entre los hallazgos posparto normales y los hallazgos asociados con sangrado secundario [
33,34 ].]. En ambos casos, el útero puede agrandarse y la cavidad endometrial puede
contener líquido, gas y/o desechos ( imagen 1A-B ). Una de las mayores fortalezas de la
ecografía radica en su valor predictivo negativo. En un estudio, ninguna paciente con grosor
endometrial <10 mm y ausencia de una masa endometrial requirió intervención [ 35 ].

La familiaridad con las fortalezas y limitaciones de las diversas modalidades de imágenes,

así como una estrecha interacción y colaboración entre los médicos tratantes y los
radiólogos, guiarán el diagnóstico y el manejo apropiados basados ​en imágenes. (Consulte
'Pruebas selectivas' a continuación).

Infección  :  los hallazgos ecográficos de endometritis suelen ser inespecíficos (

imagen 2), coincidiendo con los hallazgos posparto normales. Incluso un recuento
elevado de glóbulos blancos no es una característica distintiva. El útero puede tener un
endometrio heterogéneo y engrosado o mostrar hallazgos posparto normales comunes,
como desechos intracavitarios, líquido o gas. También puede haber tejido
placentario/membranas fetales retenidos infectados o un hematoma. La endometritis casi
siempre es un diagnóstico clínico y puede estar presente en asociación con otros hallazgos,
como RPOC. La sensibilidad durante el examen de ultrasonido y/o una mayor cantidad de
líquido y/o gas con el tiempo cuando el paciente tiene dos o más exámenes está altamente
asociado con la endometritis. Sin embargo, el gas endometrial puede verse en pacientes
posparto sin patología hasta tres semanas después del nacimiento. Complementario a la
ecografía,36 ]. En pacientes que tuvieron un parto por cesárea, la evaluación con CT
(CTA/CTV) o MRI (MRA/MRV) puede ser útil para evaluar absceso asociado o trombosis de la
vena ovárica.

Productos retenidos de la concepción (RPOC)  :  los RPOC tienen una apariencia variable
y, a veces, inespecífica en la ecografía en escala de grises. El hallazgo más sensible es un
complejo de eco endometrial engrosado (EEC) [ 37 ]. Un valor de corte de 10 mm tiene una
sensibilidad informada de más del 80 por ciento para RPOC; sin embargo, la especificidad es
relativamente baja (30 por ciento). Por otro lado, el valor predictivo negativo de un EEC
menor de 10 mm está entre 63 y 80 por ciento para RPOC.

Un hallazgo ultrasonográfico adicional importante es la detección directa de una masa

intracavitaria ecogénica sólida que se extiende hasta el endometrio. Se ha informado una
sensibilidad de hasta el 79 por ciento para este hallazgo. La ecografía Doppler color mejora
aún más la confianza y la diferenciación diagnósticas [ 38 ]. La vascularización detectable
(flujo arterial de baja resistencia) en una masa endometrial/intracavitaria es altamente
sugestiva de RPOC ( imagen 3A-B ), mientras que la falta de vascularización es compatible
con coágulos sanguíneos intrauterinos ( imagen 4 ), decidua necrótica, fragmentos de
placenta retenidos desprendidos, o RPOC avascular. El grado de vascularización en un EEC
engrosado o lesión de masa puede compararse con la vascularización miometrial y
clasificarse como tipo 0, 1, 2 o 3 [ 39]. El grado de vascularización aumenta la confianza
diagnóstica de RPOC. En el tipo 0, la ausencia de vascularización detectable en un EEC
engrosado o una lesión de masa indica un coágulo de sangre o un RPOC avascular. El tipo 0
rara vez se asocia con sangrado severo. Por otro lado, un tipo 3, caracterizado por un flujo
sanguíneo de 100 cm/seg o superior y una forma de onda espectral de resistencia muy baja,
corre el riesgo de sufrir una hemorragia grave cuando un vaso grande pierde el techo
durante el legrado [ 39 ]. En ausencia de una masa, el aumento de la vascularización en un
endometrio posparto engrosado y el aumento de la vascularización del miometrio siguen
siendo consistentes con tejido placentario retenido. La vascularización miometrial mejorada
y el aumento del flujo sanguíneo son el resultado de una involución anormal de las arterias
espirales [ 20 ].

En CT y MRI, las secuencias realzadas con contraste generalmente muestran grados

variables de realce de la lesión de masa. Las secuencias dinámicas realzadas con contraste
son particularmente útiles para graduar la vascularización de la lesión e identificar la
profundidad exacta de la invasión endometrial y miometrial [ 40,41 ]. CTA/CTV y MRA/MRV
ayudan en la diferenciación de una malformación arteriovenosa uterina (MAV). La
correlación clínica con el nivel sérico de β-hCG es útil para excluir la enfermedad
trofoblástica gestacional, que puede simular RPOC en las imágenes [ 32 ].

En raras ocasiones, la placenta retenida puede presentarse como una masa calcificada que
tiene la apariencia de tejido placentario calcificado. También en raras ocasiones, una
placenta adherente mórbida focal se presenta como HPP secundaria. Los hallazgos
ecográficos incluyen una masa que se extiende dentro o más allá del miometrio. (Consulte
"Resumen del período posparto: fisiología normal y atención materna de rutina", sección
"Hallazgos en la ecografía" .)

Subinvolución del sitio de la placenta  :  la subinvolución del sitio de la placenta (también
conocida como subinvolución de las arterias uteroplacentarias) es una afección posparto
rara que debe sospecharse cuando se observan vasos tortuosos hipoecoicos a lo largo del
tercio interno del miometrio en el lugar de la implantación previa de la placenta. sitio (
imagen 5 ) [ 42 ]. La ecografía Doppler de onda pulsada muestra un aumento de la
velocidad sistólica máxima (PSV; >0,83 m/segundo; normal 0,22 m/segundo tres días
después del parto, cayendo a 0,10 m/segundo después de seis semanas) con una forma de
onda de baja resistencia a lo largo del tercio interno del miometrio .

Existen pocos informes sobre el valor de la TC o la RM para el diagnóstico de subinvolución.

Se han descrito lagos vasculares en la interfase endometrial-miometrial posterior con un
útero aumentado de tamaño en la TC y la RM con contraste [ 32 ]. La angiografía puede
mostrar arterias uterinas hipertrofiadas y parénquima uterino que rápidamente se opacifica
y drena en venas pélvicas grandes. No debe haber comunicación directa entre la arteria y la
vena [ 43 ]. Estos hallazgos de imagen pueden simular una MAV uterina [ 20]; however, even
when systolic velocities and diastolic velocities are high and MR shows an early draining vein,
subinvolution of the placental site is the more likely diagnosis. This distinction is important
since in clinically stable patients, time and uterotonics can lead to resolution of the increased
myometrial vascularity, and thus can avoid an interventional procedure. In patients who are
clinically unstable, embolization of the uterine arteries can stabilize the patient.

Bleeding diathesis — Both bleeding diathesis and subinvolution of the placental site can
be associated with intracavitary hematomas, which can mimic the ultrasound appearance of
retained products of conception. Doppler ultrasound helps to distinguish among these
disorders.

Hematomas are not vascularized, whereas retained placental tissue may have vascular flow
within the mass on Doppler ultrasound. Patients with subinvolution and an intracavitary
hematoma may have increased PSV and low-resistance arterial flow within the myometrium
at the placental implantation site but not in the mass, and the uterus may be enlarged.

Intracavitary hematomas are typically hyperechoic on ultrasound and may be hypo- or

hyperdense on CT and hypo- or hyperintense on T1-weighted MRI depending on the age of
the hematoma. Hematomas should not enhance with contrast, if used, and typically present
with restricted diffusion characteristics (hyperintensity) on diffusion weighted imaging (DWI).

Vascular malformations — AVM and uterine artery pseudoaneurysm have characteristic

features on ultrasound and CT/CTA or MRI/MRA.

● AVM – AVMs are characterized by a high-flow arteriovenous shunting. They may be

congenital or acquired. AVM-related secondary PPH is usually due to an acquired AVM
(eg, after a curettage or a cesarean birth). Grayscale ultrasound imaging findings are
nonspecific and include multiple hypoechoic or anechoic tubular or serpentine spaces
concentrated in a small area of the myometrium adjacent to the uterine cavity. Color
and spectral Doppler examinations are essential and will show turbulent or
multidirectional blood flow in a complex tangle of vessels with high-velocity (peak
systolic velocity [PSV] ≥0.2 m/sec) and low-resistance flow (consistent with
arteriovenous shunting) on spectral analysis [44]. A PSV >0.83 m/second in vascular
malformations has been associated with a high risk of hemorrhage, a PSV <0.83
m/second has been associated with an intermediate risk, and a PSV <0.39 m/second
has been associated with a low risk [45].

CT/CTA and MRI/MRA including dynamic contrast-enhanced sequences may show

dilated, feeding arteries and enlarged, tortuous draining veins. Depiction of draining
veins in the arterial contrast phase also suggest significant arteriovenous shunting
[32]. However, as mentioned above, most patients with increased myometrial
vascularity have subinvolution of the placental site rather than an AVM. Subtle
 myometrial heterogeneity, a myometrial or endometrial mass, or prominent
parametrial vessels may be observed.

● Pseudoaneurysm – Uterine artery pseudoaneurysms are rare causes of PPH. They may
result from laceration or injury of the wall of the uterine artery branches, often after
cesarean birth or curettage. Grayscale ultrasound findings include an anechoic or
hypoechoic intrauterine lesion. Color Doppler ultrasound typically shows turbulent,
multidirectional (whirlpool) flow inside the pseudoaneurysm, often called the "yin yang"
sign. A hematoma usually surrounds the area of turbulent flow.

CT/CTA and MRI/MRA show T2-hypointense signal void in the area of the blood flow,
while the surrounding hematoma may show various densities and signal intensities
depending on the composition and age of the hematoma. On contrast-enhanced
sequences, the pseudoaneurysm usually shows a strong contrast enhancement,
including possible leakage of contrast into the uterine cavity [32]. Selective catheter
angiography combines diagnostic sensitivity and specificity with the potential to
selectively treat the pseudoaneurysm in the same session.

Hypoestrogenism — A normal-appearing uterus with a thin endometrium may be a sign of

hypoestrogenism. Patients who are breastfeeding are more likely to have hypoestrogenism
than those who are not breastfeeding.

Selective testing — If the diagnosis is uncertain after the history, physical examination,
ultrasound, and laboratory evaluation, then additional testing, such as pelvic CT/CTA or
MR/MRA as well as digital subtraction angiography, may be warranted.

● Laboratory testing that might be ordered in these cases includes: FSH, LH, TSH,
estradiol, and progesterone to rule out a possible hypoestrogenic state and to
determine the cause.

● In almost all cases, ultrasound is diagnostic to assess the patient with secondary PPH.
If there is a large amount of retained products with high velocity blood flow (greater
than 83 cm/second), then the risk of bleeding during a dilation and curettage
procedure is greater. In those cases, an interventional radiology procedure to limit flow
to the uterus prior to the procedure can be helpful. MRI is reserved for cases where 1)
it is unclear if retained products are present, for example, in a patient with fibroids
where the endometrium is poorly visualized; or 2) when placenta accreta is suspected
and the extent of the myometrial invasion is incompletely assessed with ultrasound.
While contrast-enhanced CT or MRI including DWI may be used to assess for
postpartum abscess in a patient with fever, it is not the primary imaging modality of
choice for abnormal postpartum bleeding.
MANAGEMENT

Management of common causes of secondary PPH

Initial approach — Our initial approach to management is based on the suspected

etiology of bleeding and is described in the algorithm ( algorithm 1).

Whether to initially manage secondary PPH medically or surgically is still a relatively

unstudied aspect of the care of these patients. No data from randomized trials are available
to guide management [3]. A retrospective study of 168 patients with secondary PPH
compared the outcomes of those initially managed with surgical evacuation of the uterus
with those initially managed medically [46]. The suspected causes of PPH in these cases was
not discussed. Primary surgical treatment was associated with a higher frequency of
negative primary outcomes (blood transfusion, uterine perforation after curettage, use of
broad-spectrum antibiotics, hysterectomy) than primary medical treatment (37.5 versus 16.5
percent). Approximately one-quarter of patients who were initially treated medically required
secondary surgical evacuation and 15 percent required readmission, whereas 8 percent of
those treated surgically had these outcomes. In addition, primary surgical treatment was
associated with a trend toward fewer future deliveries and an increased rate of secondary
infertility. This study suggests that a conservative medical approach may be superior to
primary surgical treatment, but is limited by selection bias and inability to analyze the data
by etiology of bleeding.

Retained products of conception — Surgical procedures (dilation and curettage, suction

curettage) are directed at evacuation of retained products of conception, which are more
common after vaginal than cesarean birth and when a vascularized endometrial mass is
noted on color Doppler ultrasound. It should be noted that retained products can be
present, even without flow. In these cases, it is the size of the mass that typically guides
decision-making. Curettage is probably the best approach when a significant amount of
tissue is present, whereas observation or pharmacotherapy of subinvolution is reasonable
when there is no or minimal tissue.

Ideally, curettage is performed under ultrasound guidance. This is likely to reduce the rate of
perforation, allow identification of placental tissue, and confirm that this tissue has been
evacuated [33]. Suction curettage should be employed when bleeding is over 500 mL and is
not controlled by medical measures. The size of the suction cannula is determined by the
size of the uterus. The diameter of the cannula is usually chosen according to the uterine
size by gestational age (eg, a 12 mm cannula for a uterus of 12 weeks size) with a minimum
diameter of 10 mm and a maximum diameter of 16 mm.
Uterine perforation and formation of intrauterine adhesions are the major complications of
surgery. In the series described above, perforation occurred in 3 percent of cases [4]. (See
"Intrauterine adhesions: Clinical manifestation and diagnosis".)

Subinvolution of the placental site — If subinvolution of the placental site is suspected,

uterotonic agents are administered. Options include:

● Methylergonovine (0.2 mg intramuscularly, repeated every two to four hours up to

three doses), or

● Carboprost tromethamine (Hemabate, 250 mcg intramuscularly; up to eight doses at

intervals at least 15 minutes apart), and/or

● Oxytocin infusion

These agents will likely not be useful if the uterus is firm, but given that the subinvolution
may be focal in some cases, a trial of uterotonic agents may still be useful even if the uterus
is not atonic. Persisting in their use when the uterus is firm is not usually helpful.

Surgical procedures (dilation and curettage, suction curettage) are often effective when
medical management fails, even if retained placental or membrane fragments cannot be
identified sonographically [4,47]. As an example, a study of 132 consecutive patients with
secondary PPH reported 75 (57 percent) were initially treated with surgical evacuation, which
was successful in 67 (90 percent) [4]. Of the 57 patients initially managed medically,
treatment was successful in 41 (72 percent); 16 patients had continuing symptoms, of whom
12 subsequently underwent surgical evacuation. Tissue specimens were obtained at surgery
in only 38 patients, and just one-third of these had histological confirmation of placental
tissue. The histologic diagnosis of placental subinvolution is based on dilated myometrial
arteries with hyaline material replacing the medial layer, partial occlusion by thrombi of
variable age, and extravillous trophoblast in and around the placental bed vessels [48,49].

Selective arterial embolization has been effective for controlling severe bleeding in high-risk
patients, who can be refractory to uterotonic drugs or uterine curettage [2,50,51]. If
percutaneous therapy fails, hysterectomy may be required.

Endometritis — If bleeding is not massive and fever, uterine tenderness, and/or a

malodorous discharge are present, then endometritis should be suspected. Under these
circumstances, we prescribe broad-spectrum antibiotic therapy ( table 2). However, some
clinicians administer antibiotics to all patients with secondary PPH, including those without
obvious signs of infection. (See "Postpartum endometritis", section on 'Diagnosis' and
"Postpartum endometritis", section on 'Treatment'.)
Rare, but potentially lethal causes of endometritis include Clostridium sordellii [52-55],
Clostridium perfringens [56], and streptococcal or staphylococcal toxic shock syndrome [57-
59]. (See "Postpartum endometritis", section on 'Endometritis with toxic shock syndrome'.)

Management of uncommon and rare causes of secondary PPH

Vascular lesions — Selective arterial embolization is the preferred approach for patients

with radiographic diagnosis of a vascular lesion as the source of bleeding [2,50,60].

Bleeding diathesis — Patients in whom a bleeding diathesis has been documented should

be treated as appropriate for the underlying disorder (refer to the relevant topic review for
the specific disorder). Consultation with a hematologist is advised.

Neoplasia — Management of patients with neoplasia depends on the specific disorder:

● Gestational trophoblastic disease ( image 6 and image 7) (see "Gestational

trophoblastic neoplasia: Epidemiology, clinical features, diagnosis, staging, and risk
stratification")

● Cervical cancer (see "Invasive cervical cancer: Epidemiology, risk factors, clinical
manifestations, and diagnosis" and "Management of early-stage cervical cancer")

● Endometrial polyp (see "Endometrial polyps")

● Adenomyosis (see "Uterine adenomyosis")

● Fibroid (see "Uterine fibroids (leiomyomas): Treatment overview")

Uterine diverticulum — A case report described severe vaginal bleeding on the 47th day
after a cesarean birth [16]. Transvaginal ultrasound examination, which showed a thickened
heteroechoic endometrium with an isolated isthmic heteroechoic cystic lesion, was not
diagnostic and curettage did not control bleeding. Because of severe bleeding, emergency
laparotomy was performed and the diagnosis of a diverticulum in the lateral wall of the
uterine isthmus was made. Obliteration of the diverticulum by sutures controlled the
hemorrhage.

Hypoestrogenism — If a hypoestrogenic state is identified, the aim is to stimulate rapid

endometrial growth with estrogen as long as there are no contraindications to hormonal
therapy. The choice of whether to administer estrogen orally or intravenously should be
based on severity of bleeding and hemodynamic status.

One option would be to use intravenous conjugated equine estrogen (20 to 40 mg) every
four hours (not to exceed a total dose of 300 mg/24 hours). Once the bleeding is controlled,
add 5 mg medroxyprogesterone acetate orally, administer one final dose of estrogen
intravenously, and begin an estrogen-progestin contraceptive pill with 35 mcg ethinyl
estradiol twice a day for 4 to 5 days, tapering to one pill daily.

Alternatively, instead of initiating intravenous conjugated equine estrogen, an oral

contraceptive pill with 35 mcg ethinyl estradiol is administered every six hours until the
bleeding is controlled, then tapered on consecutive days to 35 mcg every eight hours, every
12 hours, and then daily.

SPECIAL POPULATIONS

Severe PPH outside of the hospital setting — If PPH is severe and does not occur while the
patient is hospitalized, emergency responders can administer tranexamic acid and rapidly
transport the patient to a hospital where diagnostic evaluation and definitive therapy can be
performed. In those desperate cases in which the patient is critically unstable, the use of a
nonpneumatic anti-shock garment (NASG) may be helpful for reversing hypovolemic shock
and decreasing obstetric hemorrhage while the patient is being transported [61-63]. NASG is
discussed in more detail separately. (See "Overview of postpartum hemorrhage", section on
'Recognize alarm findings and intervene early'.)

The abdominal aortic tourniquet (external aortic compression device [EACD]) is a corset like
device that provides external aortic compression. Its use reduced morbidity and mortality
from PPH in studies from Egypt [64,65].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Obstetric
hemorrhage".)

SUMMARY AND RECOMMENDATIONS

● Definition – Secondary or late postpartum hemorrhage (PPH) is generally defined as

any significant uterine bleeding occurring between 24 hours and 12 weeks postpartum.
(See 'Definition/diagnosis' above.)

● Etiology – The most common causes of secondary PPH are retained products of
conception (including focal placenta accreta), subinvolution of the placental bed,
and/or infection. (See 'Etiology' above.)

• Less common and rare causes of secondary PPH include (see 'Etiology' above):
 - Inherited or acquired bleeding diatheses, including medications that may
predispose to bleeding
- Pseudoaneurysm of the uterine artery, internal pudendal artery, vaginal artery,
or vulvar labial artery
- Arteriovenous malformation (AVM)
- Choriocarcinoma
- Undiagnosed carcinoma of the cervix
- Adenomyosis
- Infected polyp or submucosal fibroid
- Uterine diverticulum
- Excessive bleeding with resumption of menses
- Hypoestrogenism
- Dehiscence of a cesarean scar

Sometimes the cause cannot be determined.

● Management

• Stabilize the patient – If the patient is hemodynamically unstable, stabilization is

the priority. Such patients should be evaluated in a venue suitable for surgical
intervention until sufficiently stable for transfer to a lower acuity setting.

In patients experiencing secondary PPH in the first few weeks after the birth, the
uterine cavity may be large enough to admit a balloon tamponade device, which
may be useful to limit bleeding while diagnostic evaluation occurs. (See
'Hemodynamically unstable patients' above.)

• Determine and treat the cause of bleeding – Diagnostic evaluation to determine

the cause is the priority in stable patients. Management is guided by the cause of
bleeding ( algorithm 1). In those cases where the source of bleeding is difficult to
discern, pelvic computed tomographic angiography (CTA) or magnetic resonance
angiography (MR/MRA) may allow identification of a vascular abnormality or
pseudoaneurysm that can be concurrently treated with embolization or covered
stenting. (See 'Management' above.)

• Role of surgery – Surgical procedures (dilation and curettage, suction curettage)

are often effective when medical management fails, even if retained placental or
membrane fragments cannot be identified sonographically. Arterial embolization is
another option. It should be noted that, because of the rich vascular supply of the
pelvis and perineum in pregnancy, embolization of a single vaginal or vulval supply
artery or pseudoaneurysm is unlikely to result in vaginal or perineal ischemia or
necrosis. (See 'Subinvolution of the placental site' above.)
 Use of UpToDate is subject to the Terms of Use.

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53. Rørbye C, Petersen IS, Nilas L. Postpartum Clostridium sordellii infection associated with
fatal toxic shock syndrome. Acta Obstet Gynecol Scand 2000; 79:1134.

54. Bitti A, Mastrantonio P, Spigaglia P, et al. A fatal postpartum Clostridium sordellii

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61. Turan J, Ojengbede O, Fathalla M, et al. Positive effects of the non-pneumatic anti-shock
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62. Miller S, Martin HB, Morris JL. Anti-shock garment in postpartum haemorrhage. Best
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63. Sutherland T, Downing J, Miller S, et al. Use of the non-pneumatic anti-shock garment
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Topic 113133 Version 27.0
GRAPHICS

Diagnóstico y manejo de la hemorragia posparto secundaria

Ultrasound examination in patients with secondary postpartum hemorrhage is often not definitive as th
considerable overlap between normal postpartum ultrasound findings and findings associated with seco
bleeding.
1. Ultrasound findings are often nonspecific in endometritis. The uterus may have a thickened, hete
endometrium or show common normal postpartum findings, such as intracavitary debris, fluid, o
retained placental tissue or a hematoma may be present.
2. Retained products of conception have a variable and sometimes nonspecific appearance on ultras
often appear as a solid, echogenic intracavitary mass that extends to the endometrium. However,
 decidua and blood clots can mimic retained placental fragments. Color and spectral Doppler show
velocity, low-resistance arterial flow in the mass differentiates placental tissue from hematoma bu
present in the retained tissue. In the absence of a mass, increased vascularity in a thickened postp
endometrium is also consistent with retained placental tissue. Rarely, a focal abnormally adherent
presents as secondary postpartum hemorrhage. Ultrasound findings include a mass that extends
the myometrium.
3. Bleeding diathesis and subinvolution have a similar ultrasound appearance. Ultrasound may show
postpartum findings, such as intracavitary debris, fluid, or gas. An intracavitary hematoma may be
appears as an echogenic mass, which can mimic the ultrasound appearance of retained products
However, hematomas are not vascularized, whereas retained placenta may have vascular flow on
uterus may be enlarged in subinvolution, and hypoechoic tortuous vessels are seen along the inn
myometrium. Pulsed wave Doppler sonography shows increased peak systolic velocity with a low-
waveform along the inner third of the myometrium. In patients with subinvolution and an intracav
hematoma, low-resistance arterial flow within the myometrium at the placental implantation site
confused with low-resistance arterial flow in retained placental tissue.

CBC: complete blood count; hCG: human chorionic gonadotropin.

* In patients with bleeding many weeks after giving birth, a quantitative pregnancy test is useful for eva
choriocarcinoma, retained products of conception, or even a new pregnancy.

Data from:
1. Kamaya A, Ro K, Benedetti NJ, et al. Imaging and diagnosis of postpartum complications: sonography and other imaging
Ultrasound Q 2009; 25:151.
2. Brown DL. Pelvic ultrasound in the postabortion and postpartum patient. Ultrasound Q 2005; 21:27.
3. Di Salvo DN. Sonographic imaging of maternal complications of pregnancy. J Ultrasound Med 2003; 22:69.
4. Laifer-Narin SL, Kwak E, Kim H, et al. Multimodality imaging of the postpartum or posttermination uterus: evaluation usin
computed tomography, and magnetic resonance imaging. Curr Probl Diagn Radiol 2014; 43:374.

Graphic 101276 Version 7.0

Medications and other substances that may increase the risk of bleeding
or bruising

Drug class or Mechanism

substance
Anticoagulants Interfere with clot formation (secondary hemostasis)

Antiplatelet agents, Interfere with platelet function (primary hemostasis)

including NSAIDs

Glucocorticoids Interfere with vascular integrity

Antibiotics Cause vitamin K deficiency, especially with longer use

Some interfere with platelet function

SSRIs Interfere with platelet function (primary hemostasis)

Alcohol Complications of liver disease may affect clot formation and may
cause thrombocytopenia

May cause thrombocytopenia due to direct marrow toxicity

Vitamin E Interferes with vitamin K metabolism in some individuals

Garlic Interferes with platelet function in some individuals

Gingko biloba Unknown

This is a partial list that does not include drugs used for cancer therapy or drugs that alter the
metabolism of anticoagulants. The magnitude of increased bleeding risk depends on many
factors including the patient's other bleeding risk factors and the specific drug, dose, and
duration of use. Fish oil is often cited, but bleeding risk does not appear to be increased. Refer to
drug information monographs and UpToDate topics for further information.

NSAIDs: nonsteroidal antiinflammatory drugs; SSRIs: selective serotonin reuptake inhibitors.

Graphic 120264 Version 2.0

Normal postpartum uterus with minimal fluid

Transabdominal sagittal and transverse images show an enlarged postpartum uterus with a
small amount of fluid (normal finding) in the endometrial cavity in a woman 10 days postpartum.

SAG: sagittal; ML: midline.

Courtesy of Deborah Levine, MD.

Graphic 121008 Version 1.0

Fluid and debris in postpartum uterus

(A) Transabdominal sagittal greyscale image and (B) transvaginal

color Doppler image from a 35-year-old woman two weeks
postpartum with vaginal bleeding. Note the fluid and debris in the
uterus. The color Doppler image shows no flow within the debris.

Courtesy of Deborah Levine, MD.

Graphic 73717 Version 4.0

Postpartum endometritis associated with bleeding

Postpartum patient with pain, bleeding, and fever.

(A) Transabdominal sagittal image of the uterus shows fluid within the endometrial cavity and a shaggy
irregular appearance of the endometrium anteriorly.

(B) Power Doppler image shows no blood flow to this area of the endometrium, which rules out retained
vascularized products of conception in this area. The patient was treated for endometritis and improved
clinically.

Courtesy of Deborah Levine, MD.

Graphic 101346 Version 1.0

Retained products of conception causing secondary PPH

(A) Transvaginal color Doppler shows an echogenic area with blood flow, consistent with retained produc
velocity (over 120 cm/second).

(B) Angiogram shows early filling vein (arrow). The patient was treated with embolization prior to curetta
products.

PPH: postpartum hemorrhage.

Courtesy of Deborah Levine, MD.

Graphic 101344 Version 2.0

Vascularized retained products of conception with secondary postpartum
hemorrhage

(A) Transvaginal image shows a heterogeneous mass (between caliper markers) in the endometrium of a
patient with secondary postpartum hemorrhage.

(B) Transabdominal image shows a large amount of blood flow to this endometrial region. This combina
of findings is consistent with vascularized retained products of conception.

Courtesy of Deborah Levine, MD.

Graphic 101347 Version 1.0

Blood clot in postpartum uterus

Patient with secondary postpartum bleeding.

(A) Transvaginal sonogram shows fluid in the endometrial cavity with some echogenic areas both anterio
posterior.

(B) Power Doppler image shows normal blood flow in the myometrium, and no blood flow to these areas
endometrium, which is consistent with either nonvascularized retained products of conception or blood
however, the appearance in this case is most suggestive of blood clot.

Courtesy of Deborah Levine, MD.

Graphic 101345 Version 2.0

Subinvolution of placental site

Ultrasound examination of this six weeks postpartum uterus was performed because of persistent bleed
image shows vascularity in the myometrium and notably an 8 mm vein that abuts the endometrium. No
products were seen.

Courtesy of Deborah Levine, MD.

Graphic 120878 Version 1.0

Sample antibiotic regimens for endometritis alternatives to the "Gold
Standard" gentamicin and clindamycin

Ampicillin-sulbactam 3 grams IV every 6 hours

Ticarcillin-clavulanate 3.1 grams IV every 4 hours

Cefoxitin 2 grams IV every 6 hours

Ceftriaxone 2 grams IV every 24 hours plus metronidazole 500 mg PO or IV every 8 hours*

Levofloxacin 500 mg IV every 24 hours plus metronidazole 500 mg PO or IV every 8 hours*

If chlamydia infection is suspected, azithromycin 1 gram PO for one dose should be added to the
regimen.

IV: intravenous; PO: per os.

* Should not be given to breastfeeding mothers.

Graphic 64669 Version 4.0

Ultrasound image of choriocarcinoma

Paciente con coriocarcinoma estadio 3 tras embarazo a término. Imagen

transvaginal transversa del útero que muestra una masa ecogénica
(calipers) con quistes. La masa se encuentra predominantemente en el
miometrio, separada del delgado endometrio ecogénico. Basándose
únicamente en la apariencia de la ecografía, esto podría ser un
coriocarcinoma o productos de la concepción retenidos en una paciente con
espectro de placenta acreta. Las metástasis pulmonares en la radiografía de
tórax apoyan el diagnóstico de coriocarcinoma.

Cortesía del Departamento de Radiología, Centro Médico del Valle de Santa Clara.

Gráfico 75900 Versión 4.0

coriocarcinoma por ultrasonido doppler

Coriocarcinoma: la ecografía revela una masa hiperecoica que muestra

hipervascularización en el Doppler color.

Cortesía del Departamento de Radiología, Centro Médico del Valle de Santa Clara.

Gráfico 52443 Versión 3.0

Contributor Disclosures
Michael A Belfort, MBBCH, MD, PhD, DA (SA), FRCSC, FRCOG, FACOG Participación
accionaria/Opciones sobre acciones: Glenveigh Medical [Preeclampsia]. Titular de la patente: Clinical
Innovations [hemorragia posparto]. Todas las relaciones financieras relevantes enumeradas han sido
mitigadas. Thierry AGM Huisman, MD, PD, FICIS, FACR No hay relación(es) financiera(s) relevante(s)
con empresas no elegibles para revelar. Lynn L Simpson, MD No hay relación(es) financiera(s)
relevante(s) con compañías no elegibles para revelar. Deborah Levine, MD No hay relación(es)
financiera(s) relevante(s) con compañías no elegibles para revelar. Vanessa A Barss, MD, FACOG No
hay relación(es) financiera(s) relevante(s) con compañías no elegibles para revelar.

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