Delayed Postpartum Haemorrhage

Delayed (secondary) postpartum haemorrhage is abnormal bleeding from the genital tract between 24 hours and 12 weeks after birth, most often at 7 to 14 days. Causes include retained placental tissue, endometritis, subinvolution of the placental site, scar dehiscence after caesarean section, vascular malformation, choriocarcinoma, retained pregnancy tissue and coagulopathy. It occurs in 1 to 2 percent of births, and matters because bleeding can be heavy and sudden, and infection is common.

• Risk factors: retained products, retained placenta, caesarean section, prolonged rupture of membranes, chorioamnionitis, previous postpartum haemorrhage, anaemia.
• Women are often at home when it starts.
• Ultrasound guides evacuation.

Women have heavy or prolonged vaginal bleeding with clots, offensive lochia, lower abdominal pain, fever and a bulky tender uterus, and sometimes dizziness or collapse.

• Uterus larger than expected and boggy.
• Open cervical os with clots.
• Differential diagnosis: retained products, endometritis, subinvolution of the placental site, caesarean scar dehiscence or pseudoaneurysm, cervical tear, gestational trophoblastic disease, coagulopathy, return of menstruation.
• Complications: haemorrhagic shock, sepsis, anaemia, hysterectomy, scar rupture, infertility.

The approach is clinical review with ultrasound and tests for infection and bleeding.

• Pulse, blood pressure, temperature, uterine size and tenderness, speculum examination for cervical os and discharge.
• Pelvic ultrasound with colour Doppler for retained tissue, clots, scar defect or arteriovenous malformation.
• Haemoglobin, white cell count, C-reactive protein, platelets, clotting screen, group and cross-match 2 to 4 units; high vaginal swab and blood culture if febrile.
• Urine and serum hCG (to exclude trophoblastic disease); histology of any tissue removed.

The principle is resuscitation, antibiotics, uterotonics and evacuation of retained tissue.

• Supportive: admit if bleeding is heavy or the woman is unwell; two cannulae; Ringer's lactate 1 litre if shocked; transfuse for haemoglobin below 7 g/dL or shock; uterine massage; empty the bladder.
• Pharmacological: oxytocin 10 IU IM then infusion of 40 IU in 1 litre Ringer's lactate at 250 mL per hour; misoprostol 800 micrograms sublingual once; ergometrine 0.2 mg IM once, or methylergometrine 0.2 mg oral 8-hourly for 3 days (not in hypertension); tranexamic acid 1 g oral or IV 8-hourly for 3 days; ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly until afebrile for 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days; ferrous sulphate 200 mg oral 8-hourly for 3 months.
• Procedures: evacuation of retained tissue with suction or a blunt curette under antibiotic cover and ultrasound guidance (after the first dose of antibiotics); balloon tamponade (300 to 500 mL sodium chloride 0.9 percent); uterine artery embolisation for a vascular malformation or pseudoaneurysm; repair of scar dehiscence; hysterectomy for uncontrolled bleeding or necrotic uterus.
• Red flags: heavy bleeding, shock, fever above 38 degrees Celsius, foul discharge, severe pain, persistently raised hCG.
• Follow-up: haemoglobin at 24 hours and 2 weeks; ultrasound at 1 to 2 weeks after evacuation; histology review; hCG if tissue shows trophoblast; review at 6 weeks.