A woman develops secondary PPH 12 days postpartum with subinvoluted uterus and retained placental tissue confirmed on ultrasound. Her hCG is persistently elevated at 620 mIU/mL. Which additional investigation is mandatory before proceeding to curettage?

• A Pelvic Doppler ultrasound to exclude arteriovenous malformation ✓
• B MRI pelvis to assess myometrial invasion
• C Chest X-ray to exclude pulmonary metastases given the elevated hCG
• D Coagulation profile to rule out coagulopathy before curettage

Explanation

Secondary PPH with persistently elevated hCG after 10–12 days postpartum must be distinguished from gestational trophoblastic disease (GTD) AND from postpartum uterine arteriovenous malformation (AVM) before curettage. Curettage of an AVM can cause catastrophic haemorrhage. Colour Doppler or MRI angiography to exclude AVM is mandatory when PPH with high-flow lesions is suspected. While hCG elevation raises concern for GTD (where CXR matters), the immediate pre-curettage priority is excluding vascular abnormality.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.