Secondary postpartum haemorrhage — structured SAQ (15 marks)

(a) Causes and their relationship (2 marks)

• The two commonest causes are retained products of conception and endometritis, and in most women they coexist rather than compete — which is why the standard answer is antibiotics plus a decision about the cavity, not antibiotics or evacuation.[1]
• One mark for naming the four dangerous rarer causes: pseudoaneurysm, arteriovenous malformation, scar dehiscence, gestational trophoblastic neoplasia.[5][6]

(b) Immediate management priorities (4 marks)

One mark per point, maximum four. [1]

• Observations and shock index — she is already at risk because she was anaemic after the index primary PPH; the same loss hits a smaller reserve harder.[1]
• Resuscitation if bleeding is major — two large-bore cannulae, bloods including group and hold or crossmatch, coagulation, FBC; tranexamic acid and a uterotonic if she is bleeding now (an extrapolation from the primary PPH evidence, not a trial-proven indication here).[1]
• Speculum and bimanual examination — quantify the bleeding, look at the os; tissue visible at an open os can be removed with sponge forceps at the bedside and frequently stops the bleeding immediately.[1]
• Antibiotics covering aerobes and anaerobes — clindamycin plus gentamicin is the Cochrane reference regimen; take swabs first if it does not delay the dose.[4]

(c) The role of ultrasound (4 marks)

One mark each for the four points. [3]

• Ultrasound is a rule-in test with a poor rule-out — say this explicitly.[3]
• The useful positive finding is an echogenic endometrial mass with colour Doppler flow, not an echogenic stripe (frequently clot and decidua).[3]
• In a modern cohort of 212 women taken to hysteroscopy, a 7 mm threshold gave a positive predictive value of about 75% and a negative predictive value of only about 50%.[3]
• A cystic myometrial lesion with turbulent high-velocity Doppler flow changes the management to suspected pseudoaneurysm — Doppler, interventional radiology, and no curette.[5][6]

(d) Consent, operative principles, and the pseudoaneurysm trap (5 marks)

Consent (2), operative principles (2), the trap (1). [1]

• Consent: name uterine perforation (three in 132 in the classic series, one needing hysterectomy) and Asherman syndrome (intrauterine adhesions affecting future fertility); state that only a minority of evacuated women actually have retained tissue confirmed (37% in the classic series), so operating on clot is a real harm.[1]
• Operative principles: senior operator, theatre, ultrasound guidance, suction rather than sharp curettage, oxytocin and antibiotic cover; the infected two-week uterus is soft and thin — this is where perforations happen.[1]
• The trap: torrential bleeding with an apparently empty cavity is a uterine artery pseudoaneurysm until proven otherwise — resuscitate, do not curette, get Doppler and call interventional radiology for embolisation.[5][6]