Secondary postpartum haemorrhage

She gave birth twelve days ago. She has come back through the emergency department, for the second time, passing clots and looking pale, and the resident has written "lochia" in the notes. This is the topic where an unglamorous diagnosis is missed until it becomes an emergency — and where the rare diagnosis behind the common one is the thing that kills.^[1][9]

Overview and definition

Secondary PPH is excessive or abnormal bleeding from the genital tract after the first 24 hours following birth. ^[1][13]

• The upper limit is not agreed. Classic definitions stop at 6 weeks; the modern systematic-review literature uses 24 hours to 12 weeks, which better matches when women actually present.^[2][13]
• Volume is not in the definition. Unlike primary PPH there is no millilitre threshold — the judgement is whether bleeding is heavier or later than expected for the puerperal day.^[1]
• It is a different disease from primary PPH. Primary PPH is a tone and trauma problem solved in minutes. Secondary PPH is a tissue and infection problem solved over days, with a small vascular subset that behaves like a primary catastrophe.^[1][8]

References20ShowHide

1. [1]Hoveyda F, MacKenzie IZ Secondary postpartum haemorrhage: incidence, morbidity and current management. BJOG, 2001.PMID 11563461
2. [2]Fox R, Aitken G, Mooney SS Management of secondary postpartum haemorrhage: A systematic review. Eur J Obstet Gynecol Reprod Biol, 2023.PMID 36708658
3. [3]Fox R, Anderson J, Young N, et al. Medical management of secondary postpartum haemorrhage: A prospective cohort study. Aust N Z J Obstet Gynaecol, 2023.PMID 35699126
4. [4]Alexander J, Thomas P, Sanghera J Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev, 2002.PMID 11869640
5. [5]Yagur Y, Jurman L, Weitzner O, et al. Ultrasound for diagnosis of postpartum retained products of conception-How accurate we are? BMC Pregnancy Childbirth, 2023.PMID 37563560
6. [6]Steinkeler J, Coldwell BJ, Warner MA Ultrasound of the postpartum uterus. Ultrasound Q, 2012.PMID 22572864
7. [7]Iraha Y, Okada M, Toguchi M, et al. Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. Jpn J Radiol, 2018.PMID 29052024
8. [8]Alonso-Burgos A, Díaz-Lorenzo I, Muñoz-Saá L, et al. Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach. CVIR Endovasc, 2024.PMID 38349501
9. [9]Tsai YL, Cheong ML Uterine artery pseudoaneurysm: Rare cause of delayed postpartum hemorrhage. Taiwan J Obstet Gynecol, 2026.PMID 42362268
10. [10]Mackeen AD, Packard RE, Ota E, et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev, 2015.PMID 25922861
11. [11]Conde-Agudelo A, Romero R, Jung EJ, et al. Management of clinical chorioamnionitis: an evidence-based approach. Am J Obstet Gynecol, 2020.PMID 33007269
12. [12]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
13. [13]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
14. [14]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
15. [15]van Wessel S, Coryn N, van Vliet H, et al. Reproductive and Obstetric Outcomes After Hysteroscopic Removal of Retained Products of Conception. J Minim Invasive Gynecol, 2020.PMID 31352066
16. [16]Ben-Ami I, Melcer Y, Smorgick N, et al. A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception. Int J Gynaecol Obstet, 2014.PMID 24997472
17. [17]Wagenaar LP, van Vliet HA, Radder CM, et al. Operative hysteroscopy versus ultrasound-guided electric vacuum aspiration for removal of retained products of conception: A prospective cohort study. Eur J Obstet Gynecol Reprod Biol X, 2023.PMID 37701632
18. [18]Deans R, Vancaillie T, Ledger W, et al. Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome. Hum Reprod, 2018.PMID 30239778
19. [19]Dawood A, Al-Talib A, Tulandi T Predisposing factors and treatment outcome of different stages of intrauterine adhesions. J Obstet Gynaecol Can, 2010.PMID 21050509
20. [20]Ngan HYS, Seckl MJ, Berkowitz RS, et al. Diagnosis and management of gestational trophoblastic disease: 2025 update. Int J Gynaecol Obstet, 2025.PMID 40631439