Secondary Postpartum Haemorrhage

Secondary (delayed or late) postpartum haemorrhage is abnormal or excessive vaginal bleeding from 24 hours to 12 weeks after delivery. It occurs in about 1 to 3% of deliveries (more after caesarean or with retained products), and is most often seen between days 7 and 14.

Causes:

• retained products of conception (placental fragments or membranes, the commonest cause, about 30 to 40%)
• endometritis and subinvolution of the placental site (about 20 to 30%)
• uterine artery pseudoaneurysm or arteriovenous malformation (rare, but life threatening)
• caesarean scar dehiscence or niche
• gestational trophoblastic disease (choriocarcinoma)
• coagulopathy (von Willebrand disease, factor XI deficiency; bleeding peaks at 1 to 3 weeks postpartum in von Willebrand disease when VWF levels return to baseline)
• cervical or vaginal lacerations or haematomas
• uterine fibroids

• Heavy or prolonged vaginal bleeding after the first 24 hours; episodic, often with clots, can be sudden and heavy
• Offensive lochia, fever, abdominal pain or uterine tenderness (endometritis)
• Subinvolution: enlarged soft uterus; open cervical os
• Signs of anaemia and hypovolaemia
• Pelvic pain or mass with haematoma; wound discharge after caesarean scar dehiscence

• Clinical evaluation: vital signs, uterine size and tenderness, speculum examination for lacerations or cervical bleeding, and assessment of lochia
• Laboratory:
  • full blood count, C-reactive protein, coagulation profile
  • VWF antigen and activity (if history of bleeding)
  • serum beta-hCG (to exclude retained trophoblast or GTN)
  • group and crossmatch
  • blood cultures if febrile, and high vaginal and endocervical swabs (chlamydia, gonorrhoea)
• Pelvic ultrasound (transvaginal) shows:
  • retained products (thickened endometrium above 10 to 15 mm with heterogeneous echogenic mass and vascularity on Doppler)
  • collections, haematometra, scar niche
  • arteriovenous malformation (turbulent flow)
  Use Doppler or CT angiography for pseudoaneurysm (when bleeding persists after curettage).
• MRI if the cause remains unclear

• Resuscitation if heavy bleeding: oxygen, IV access, fluids and transfusion, tranexamic acid 1 g IV (or 1 g orally three times daily for 5 days for lesser bleeding).
• Uterotonics: oxytocin infusion, ergometrine 0.25 mg IM or oral 0.2 mg three times daily (if not hypertensive), misoprostol 800 micrograms sublingually or rectally.
• Antibiotics for endometritis or possible infection (even without fever): amoxicillin clavulanate 625 mg three times daily orally, or IV clindamycin 900 mg every 8 hours with gentamicin 5 mg/kg daily, plus metronidazole; continue for 5 to 7 days.
• Retained products: evacuation of the uterus under ultrasound guidance and antibiotic cover (suction curettage preferred over sharp curettage to reduce perforation and adhesions); histology of tissue (exclude GTN).
• Pseudoaneurysm or AVM: uterine artery embolisation (the preferred therapy, high success); avoid curettage if arteriovenous malformation is suspected.
• Persistent bleeding: balloon tamponade, embolisation, laparotomy with compression suture, or hysterectomy.
• Coagulopathy: desmopressin 0.3 micrograms/kg IV or VWF concentrate, tranexamic acid, and haematology input.
• Caesarean scar dehiscence: surgical repair or hysterectomy.
• GTN: refer to a trophoblastic disease centre for hCG monitoring and chemotherapy.
• Iron replacement and anaemia treatment; follow up at 6 weeks.