Brief Answer: Do not be scared. Detailed Answer: Hi XXXXXXX and welcome to HCM, I understand that you have been through a lot and are still in pain. Please do not feel scared. The only issue id that the diagnosis is not yet there and hence maybe these issues. I understand that you are 7 weeks post partum and this was a cesarean section. You have been bleeding since two weeks after delivery off and on and the bleeding has been bright and heavy. An ultrasound was done and something was seen inside, second ultrasound was normal and nothing was seen. There are few possibilities with this type of history: 1. Retained bits of tissue inside the uterus. This leads to heavy bleeding and may also cause infection. The antibiotics may cover up but may not have been very effective and hence the bleeding. For this you will need a cervical swab culture test and total and differential leucocyte counts.[ Further investigations will be explained in the end] 2. Poor healing of the placental bed leading to sloughing and the underlying blood vessels get exposed and bleed. 3. Gestational trophoblastic disease especially a choriocarcinoma; very very rare. It is a tumor of the placenta. Gives rise to a positive urine pregnancy test. 4. Anomalies in the blood vessels of the uterus or endometrium leading to bleeding. 5. Bleeding disorders where blood does not clot easily and produces heavy bleed. Unlikely as you would have bled during C section also. 6. Drugs like aspirin that produce heavy bleeding. Other causes include fibroids that are not relevant in your case as they have not been seen on ultrasound. The investigation plan for all these is: Check if you are using any drugs that may interfere with coagulation. Get a urine pregnancy test done to rule out raised HCG levels associated with choriocarcinoma. A blood quantitative HCG test may also be done. Then a cervical, vaginal swab and urine microscopy for blood and culture will be needed. A hemogram and total plus differential leucocyte count will help to diagnose infection. A transvaginal ultrasound by another doctor will be required to avoid bias and also a second opinion. A doppler will be needed to detect any vascular abnormality. If all of these are negative an MRI of the pelvis will help to visualise if there is any soft tissue defect. Meanwhile you may ask your doctor for medicines to control bleeding like tranexamic acid. Other drugs like progesterone preparations may also be started after investigations are drawn. Also a change of antibiotics and a higher group drug with broader spectrum may be helpful if there is infection. Also since you have lost a lot of blood, start hematinics like iron and b complex vitamins, eat a healthy diet rich in carrots, beet, apples and a piece of meat. You will be alright. Get the tests done and rest. These are not uncommon issues in the place where I practice and we deal with them as a routine. So do not worry. Hope I was able to help you, Thanks for using HCM. Feel free for any more queries and I am here to help. Dr Madhuri Bagde Consultant Ob Gyn

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