recurrent secondary postpartum hemorrhage with HB 7 gm% , empty cavity , no fever or offensive lochia and ultrasound free. what are the possible diagnoses?
If there is systemic coagulopathy it could be. In such case we have low platelet count and positive tests for fibrin degradation. Sometimes the abnormality of platelet agregation may produce such complication. But if the only problem is incisional site hematoma we are to observe and use antifibrinolytics and antianemic medications additionally to routine postcesarean management.
Uterine scar site abnormal neo-vasculature can be a source of torrential secondary PPH. These vessels would lead to segmental sacculations as the muscle coat in these vessels is defective. One of these saccule may burst after getting distended & would gush out blood in great quantity. After a while, as the BP falls, the bleeding would stop & one will feel secure that everything is all-right. After a few days another saccule will distend and may rupture! This can be life threatening. One should not neglect such PPH especially if it is second time! I have personal experience as well as had discussion with many senior colleagues in this regard. Nowadays a color doppler of scar area may help detect this. Scar freshening (if the patient is stable) and at times a hysterectomy will be necessary.
I totally agree with Dr. Parul about his opanian. You have also to think about possibility of choriocarcinoma (send for B-hCG) and bleeding disorder.
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