Secondary Postpartum Haemorrhage
Summary
Secondary Postpartum Haemorrhage (PPH) is defined as excessive vaginal bleeding occurring from 24 hours after delivery up to 12 weeks postpartum. Unlike primary PPH, which is usually due to uterine atony, secondary PPH is most commonly caused by infection (endometritis) or retained products of conception (RPOC). It is a major cause of maternal morbidity, necessitating readmission, antibiotics, and occasionally surgical intervention.
Key Facts
- Definition: Abnormal or heavy PV bleeding observed between 24 hours and 12 weeks postnatal.
- Prevalence: Occurs in 1-3% of all pregnancies.
- Mortality/Morbidity: While mortality is rare in high-resource settings, morbidity is significant due to sepsis potential and surgical risks (perforation).
- Key Management: Treat the cause: Antibiotics for infection, Surgical Evacuation for retained tissue.
- Critical Threshold: Any signs of haemodynamic instability or sepsis trigger immediate resuscitation protocols.
- Key investigation: Ultrasound (Pelvic) to identify retained tissue and thickened endometrium.
Clinical Pearls
The "Soft" Uterus: In secondary PPH, the uterus is often subinvoluted (larger than expected for dates), soft, and tender. This contrasts with the firm, contracted uterus of a normal puerperium.
Group A Strep (GAS): Be terrified of Group A Streptococcus. It can cause rapid, fulminant sepsis with minimal local signs initially. If a woman feels "flu-like" with pelvic pain, treat aggressively.
The Ultrasound Trap: Ultrasound is good at seeing tissue, but bad at saying what it is. Blood clots and necrotic decidua can look exactly like retained placental tissue. Do not operate on ultrasound findings alone if the clinical picture suggests pure infection.
Why This Matters Clinically
Secondary PPH is the leading cause of readmission in the puerperium. It disrupts bonding, breastfeeding, and maternal recovery. Furthermore, surgical management (ERPC) in the postpartum uterus carries a significantly higher risk of uterine perforation (soft, boggy walls) and Asherman's syndrome (adhesions) compared to non-postpartum procedures.
Incidence & Prevalence
- Incidence: 0.5% to 2% of deliveries (varies by definition).
- Trend: Rising slightly, possibly linked to increasing caesarean section rates and maternal age.
- Timing: Most cases present in the second week postpartum (Days 7-14), when the "eschar" at the placental site sheds.
Demographics
No strong ethnic predisposition, though socioeconomic factors delaying care seeking can worsen outcomes.
Risk Factors
Antepartum:
- Placental abnormalities: Placenta praevia, accreta spectrum.
- Multiparity: Poor uterine tone.
Intrapartum:
- Prolonged labour: Risk of chorioamnionitis.
- Instrumental delivery: Introduced infection.
- Manual Removal of Placenta (MROP): Highest risk factor for both infection and missed tissue lobes.
- Caesarean Section: Higher infection risk than NVD.
Postpartum:
- Meconium staining: Bacterial growth medium.
- Low hygiene: Rare in high resource, relevant globally.
| Risk Factor | Relative Risk | Interpretation |
|---|---|---|
| Manual Removal of Placenta | High | Known interference with placental bed. |
| History of Secondary PPH | Moderate | Recurrence risk exists. |
| Maternal Age > 35 | Low | Weak association. |
Mechanism: The "4 Ts" of Secondary PPH
While Primary PPH is mostly "Tone", Secondary PPH biology is different.
1. Tissue (Retained Products - MOST COMMON)
- Small cotyledons or succenturiate lobes of the placenta remain adherent.
- Necrotic decidua prevents the uterus from contracting fully (subinvolution).
- The tissue acts as a nidus for infection.
- Mechanism: The "living ligatures" (criss-crossing muscle fibres) cannot seal the spiral arteries because the tissue physically blocks contraction.
2. Infection (Endometritis)
- Ascending infection from vaginal flora (E. coli, Bacteroides, GBS, GAS).
- Bacteria colonize the placental site (a large raw wound).
- Inflammation causes vasodilation and tissue friability, leading to bleeding.
3. Tone (Subinvolution)
- Failure of the uterus to return to non-pregnant size.
- Usually secondary to Tissue or Infection rather than primary muscle failure at this stage.
4. Thrombin (Coagulopathy)
- Rare in secondary PPH unless Von Willebrand Disease usually presents delayed.
- Warfarin/heparin therapy postpartum.
Physiology of Involution
- Immediately post-delivery: Uterus is at umbilicus level (~1kg).
- 1 week: Mid-way symphysis-umbilicus (~500g).
- 2 weeks: Not palpable abdominally (pelvic organ).
- 6 weeks: Pre-pregnant size (~60g).
- In Secondary PPH, the fundus is often palpable abdominally at 2-3 weeks.
Symptoms
Typical Presentation:
Atypical Presentations:
Signs
Red Flags
[!CAUTION] Red Flags — Identify Sepsis Immediately
- Maternal Sepsis is a killer.
- If HR > 110, RR > 24, Temp > 38 or < 36:
- Initiate SEPSIS SIX protocol immediately.
- Do not wait for blood results.
- Give IV Antibiotics within the hour.
Structured Approach
General:
- Observation: Is the patient pale, sweaty, or flushed (septic)?
- Vitals: Vital for early warning score (MEWS/MOEWS).
Abdominal:
- Palpate fundal height. Is it firm or boggy? Is it tender?
- Bladder: Ensure not distinctively full (can displace uterus).
Pelvic (Bimanual/Speculum):
- Speculum: Essential. Visualize the cervix. Remove clots with sponge forceps (can be curative if clot was holding os open). Take swabs.
- Bimanual: Assess uterine size (mobility, tenderness). Cervical excitation pain suggests pelvic inflammatory spread.
Special Tests (Bedside)
- High Vaginal Swab (HVS): Mandatory.
- Quantitative hCG: To rule out molar pregnancy/choriocarcinoma if clinically ambiguous.
Laboratory Tests
| Test | Expected Finding | Purpose |
|---|---|---|
| FBC | Anaemia (Hb <100), Neutrophilia (>5) | Assess blood loss and infection. |
| CRP | Elevated (>0 usually) | Inflammatory marker/Sepsis monitor. |
| Coagulation | Usually normal | Exclude DIC in severe sepsis. |
| Blood Culture | Positive in 10-20% | Golden standard for targeted antibiotics. |
| Group & Save | N/A | Essential preparation for potential transfusion. |
Imaging (Ultrasound)
The modality of choice.
| Modality | Findings | Indication |
|---|---|---|
| Transvaginal US | Thickened endometrial stripe, echogenic mass | Suspected RPOC. |
| Doppler Flow | Vascularity within the mass | Differentiates RPOC (vascular) from Clot (avascular). |
Note: A "thickened" endometrium alone is normal postpartum. Diagnosis relies on a discrete mass with blood flow.
Diagnostic Criteria
- Clinical: Heavy bleeding + Fever + Tender Uterus = Endometritis (Treat medically).
- Radiological: Above + Echogenic Mass on Scan = RPOC (Consider surgical).
Management Algorithm
(See Section 2 for ASCII)
Acute/Emergency Management (The Sepsis Six)
If septic features present:
- Give O2: Keep sats >94%.
- Take Blood Cultures: Before antibiotics.
- Give IV Antibiotics: Broad spectrum.
- Give IV Fluids: Hartmann's or Normal Saline 500ml-1L bolus.
- Check Lactate: Marker of tissue hypoperfusion.
- Monitor Urine Output: Hourly measurement (catheter).
Medical Management (Antibiotics)
Start broad, then narrow based on swabs.
| Regimen | Drugs | Rationale |
|---|---|---|
| First Line | Co-amoxiclav 1.2g IV TDS + Metronidazole 500mg IV TDS | Covers Gram+ (Strep), Gram- (E.coli), Anaerobes. |
| Penicillin Allergy | Cefuroxime 1.5g IV TDS + Metronidazole | Avoid if anaphylaxis to penicillins (cross-reactivity). |
| Severe Allergy | Clindamycin 900mg IV Qds + Gentamicin (wt based) | Broad cover for severe allergy. |
Duration: usually IV until apyrexial for 24 hours, then switch to oral for 5-7 days.
Medical Management (Uterotonics)
To encourage uterine contraction and expulsion of contents.
| Drug | Dose | Route | Contraindications |
|---|---|---|---|
| Syntocinon (Oxytocin) | 5-10 IU | IV Slow inj | Hypotension (if rapid). |
| Ergometrine | 500 mcg | IM | Hypertension / Preeclampsia. |
| Misoprostol | 800 mcg | PR/PV/Subling | Asthma (relative). |
| Carboprost | 250 mcg | IM Deep | Asthma (causes bronchospasm). |
Surgical Management
Evacuation of Retained Products of Conception (ERPC)
Indications:
- Persistent bleeding despite medical treatment.
- Significant retained tissue visible on US (>20mm usually).
- Heavy haemodynamic instability.
Risks (Higher than miscarriage ERPC):
- Perforation: The postpartum uterus is notoriously soft ("like butter"). Risk is high.
- Asherman's Syndrome: Aggressive curettage removes the basalis layer, causing scarring and future infertility. Note: Use suction curettage, avoid sharp curettage.
- Infection spread: Operating on an infected organ can seed bacteria into bloodstream. Always cover with antibiotics 'intra-op'.
Disposition
- Admit: Almost all established cases require IV antibiotics for 24-48h.
- Discharge: Once apyrexial x 24h, bleeding settled, Hb checked.
- Follow-up: Debrief regarding future pregnancy risks (if perforation/Asherman's).
Immediate
- Sepsis/Septic Shock: Leading cause of direct maternal death globally.
- ICU Admission: For cardiovascular support.
- Hysterectomy: Last resort for uncontrollable sepsis/bleeding (removing the source).
Early (Days)
- Pelvic Abscess: Collection of pus requiring drainage.
- Septic Pelvic Thrombophlebitis: Infected clot in ovarian vein. Persistent fever despite abx. Requires heparin.
Late (Weeks-Months)
- Asherman's Syndrome (Intrauterine Adhesions):
- Cause: Over-zealous curettage of the post-partum uterus.
- Effect: Amenorrhoea, Hypomenorrhoea, Infertility, Recurrent Miscarriage.
- Prevention: Ultrasound-guided suction evacuation rather than blind sharp curettage.
- Infertility: Tubal blockage from spread of infection (salpingitis).
Natural History
With prompt antibiotic treatment, most cases of endometritis resolve within 48-72 hours without surgical intervention.
Outcomes with Treatment
- Medical Success: ~70-80% of Secondary PPH resolves with antibiotics and uterotonics alone, even with small amounts of retained tissue (which passes spontaneously).
- Surgical Success: ERPC stops bleeding immediately but carries the mentioned procedural risks.
Prognostic Factors
Poor Prognosis (Risk of Hysterectomy/Death):
- Group A Streptococcus infection (Necrotizing fasciitis/Toxic Shock).
- Delayed presentation.
- Immunocompromised state.
Key Guidelines
- RCOG (Royal College of Obstetricians and Gynaecologists) — Green-top Guideline No. 52: Prevention and Management of Postpartum Haemorrhage. The gold standard UK guideline.
- ACOG (American College of Obstetricians and Gynecologists) — Postpartum Hemorrhage. Practice Bulletin.
Landmark Trials
The WOMAN Trial (2017)
- Effect of early tranexamic acid on mortality in postpartum haemorrhage.
- Key finding: TXA reduces death due to bleeding by ~30% if given within 3 hours.
- Clinical Impact: While primarily for Primary PPH, the principle of antifibrinolytic utility extends to managing significant secondary bleeding episodes.
Antibiotic Prophylaxis for Manual Removal (Cochrane)
- Finding: Routine antibiotics after manual removal of placenta significantly reduce the rates of postpartum endometritis.
- Clinical Impact: Prevention is part of the cure.
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Broad Spectrum IV Abx | 1b | Standard of care derived from sepsis trials |
| Misoprostol for PPH | 1a | Cochrane reviews confirming efficacy |
| Ultrasound Diagnosis | 2b | High sensitivity for tissue detection |
What is Secondary PPH?
It is heavy bleeding that happens after the first 24 hours of birth, sometimes up to 12 weeks later. Most bleeding slowly stops over weeks (lochia), but if it suddenly gets heavier, bright red, or smells bad, it is abnormal.
Why does it matter?
It usually means there is an infection in the womb (uterus) or a small piece of the afterbirth (placenta) was left behind. If untreated, the infection can spread to the blood (sepsis), which is very dangerous.
How is it treated?
most often, we can treat it with medicine alone:
- Antibiotics: Strong antibiotics through a drip to kill the bacteria.
- Tablets to contract the womb: To help squeeze out any clots.
- Surgery (D&C): If there is a large piece of placenta left, a doctor might need to carefully remove it while you are asleep. We try to avoid this if possible because the womb is soft and fragile after birth.
When to seek help
Call your midwife or go to A&E immediately if:
- You are soaking more than one pad an hour.
- You pass clots larger than a 50p coin (or golf ball).
- You have a fever, shivers, or feel flu-like.
- The discharge smells very bad.
Primary Guidelines
- Mavrides E et al. Prevention and Management of Postpartum Haemorrhage. BJOG. 2016;124(5):e106-e149. (RCOG Green-top Guideline No. 52). PMID: 27981719
- Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. PMID: 28937571
Key Trials
- WOMAN Trial Collaborators. Effect of early tranexamic acid on death, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. PMID: 28456509
- Alexander J et al. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev. 2002.
Further Resources
- RCOG Patient Information: Heavy bleeding after birth
- Sepsis Trust: Maternal Sepsis
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.