Secondary Postpartum Hemorrhage

Definition & Etiology - Late Bleed Basics

• Definition: Secondary Postpartum Hemorrhage (PPH) is excessive uterine bleeding occurring from >24 hours after delivery up to 6-12 weeks postpartum. It's distinct from primary PPH (first 24 hours).
• Incidence: Affects ~0.2-2% of pregnancies, a notable postpartum complication.
• Etiology (Common Causes): 📌 Mnemonic: R.E.S.C.
  • Retained Products of Conception (RPOC): Placental fragments/membranes left in uterus. Most common.
  • Endometritis: Infection of the uterine lining (endometrium), causing inflammation and bleeding.
  • Subinvolution of placental site: Impaired uterine contraction and return to normal size at the placental attachment area.
  • Coagulopathies: Inherited (e.g., von Willebrand disease) or acquired bleeding disorders.

⭐ Retained products of conception (RPOC) is the most common cause of secondary PPH.

Diagnosis & Investigations - Spotting the Source

• Clinical Presentation:
  • Bleeding: Persistent or sudden gushes of bright red blood; may be foul-smelling if infection (endometritis) is present. Occurs between >24 hours and 12 weeks postpartum.
  • Uterus: Often subinvoluted (larger and softer/boggy than expected for the postpartum period), may be tender on palpation.
  • Systemic signs: Fever, chills, and lower abdominal/pelvic pain can indicate associated endometritis.
• Essential Investigations:
  • Pelvic Ultrasound (USG): Crucial first-line investigation.
    • Identifies Retained Products of Conception (RPOC): Look for an echogenic mass within the uterine cavity, often with ↑vascularity on Doppler.
    • Assesses uterine size for subinvolution.
    • 
  • Laboratory Tests:
    • Complete Blood Count (CBC): To assess degree of anemia (↓Hb, ↓Hct) and detect leukocytosis (↑WBC) suggesting infection.
    • Coagulation Screen (PT, aPTT, fibrinogen): Essential if excessive bleeding or suspected coagulopathy.
    • Blood Cultures: Indicated if the patient is febrile to identify pathogens in case of sepsis.
• Diagnostic Algorithm:

⭐ Pelvic ultrasound is the cornerstone of investigation for suspected secondary PPH, pivotal for identifying structural causes like RPOC or subinvolution.

Management - Stopping the Flow

• Initial Steps:
  • ABCs; Resuscitate if unstable (IV fluids, blood).
• Medical Management:
  • Uterotonics:
    • Oxytocin: 10-40 U in IV infusion.
    • Ergometrine: 0.2-0.25mg IM/IV (⚠️ Avoid in HTN).
    • Misoprostol: 800-1000mcg per rectum (PR) or 600-800mcg sublingual (SL)/per oral (PO).
    • Carboprost: 0.25mg IM (⚠️ Avoid in asthma).
  • Tranexamic Acid: 1g IV over 10 min, repeat if needed (max 2g).
  • Antibiotics for endometritis (e.g., Clindamycin + Gentamicin).

    ⭐ Broad-spectrum antibiotics are crucial if endometritis is suspected or confirmed as the cause.

• Surgical Management:
  • Examination Under Anesthesia (EUA): Identify trauma, RPOC.
  • Suction Evacuation / Dilatation & Curettage (D&C): For RPOC.
  • Uterine Artery Embolization (UAE): If available & patient stable.
  • Laparotomy:
    • Uterine repair.
    • Artery ligation (uterine, internal iliac).
  • Hysterectomy: Last resort.

High‑Yield Points - ⚡ Biggest Takeaways

• Secondary PPH is abnormal bleeding from 24 hours to 12 weeks postpartum.
• Most common cause is retained products of conception (RPOC).
• Other key causes include subinvolution of placental site and endometritis.
• Ultrasound is crucial for diagnosing RPOC.
• Management involves uterotonics, antibiotics for infection, and D&C for RPOC.
• Consider underlying coagulopathies like von Willebrand disease.
• Rare causes: Uterine artery pseudoaneurysm or AV malformation_