The most efficacious treatment of persistent uterine hemorrhage in the second to fourth week of the puerperium, as observed in this patient is which of the following?
1.dilation and curettage (D&C)
2.Ergotrate
3.high doses of estrogen
4.high doses of progesterone
5.Uterine packing
sol:
Retained placenta and subinvolution of the placental sites are common causes of late puerperal bleeding. Ergotrate causes cramping, but does not often resolve the problem. Severe hemorrhage can occur during a D&C and should be anticipated in high-parity women possibly because the placenta is implanted lower in the uterus with each subsequent pregnancy. The possibility of removing all of the endometriumand creating Asherman’s syndrome must be kept in mind, especially if there is an infection. Placental polyps and gestational tro-phoblastic disease are rare causes that should be remembered. Uterine packing will not remove the retained placental fragments. Unless there is severe atony, estrogen will not help.