Secondary PPH

Abnormal bleeding from 24 hours to 6 weeks after birth, usually occurring at 10-14 days afterwards. 

Causes:

• Endometritis

  • • RFs include C-section, PROM, long duration of labour

• Retained placental tissue

• Placental site involution (inadequate closure and shedding of the spiral arteries at the placental attachment site).

• Trophoblastic disease (very rare).

Risk factor:

Previous Hx - Secondary PPH has a recurrence rate of 20–25%.

Presentation:

• Spotting for days with occasional fresh blood

• Around 10% cases present with massive haemorrhage 

Women with endometritis may also present with:

• Fever/rigors

• Lower abdo pain

• Foul smelling discharge

O/E:

• Women with retained placenta may have a high uterus on palpation

• Speculum examination is important in order to assess the amount of bleeding, and a high vaginal swab should be taken at the same time.

A pelvic ultrasound scan can assist in the diagnosis of retained placental tissue.

Note: US is particularly helpful in excluding a diagnosis of retained placental tissue due to its high NPV. 

Management

• Antibiotics – usually a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole.

  • Gentamicin should be added to the above combination in cases of endomyometritis (tender uterus) or overt sepsis.

• Uterotonics – examples include:

  • • Syntocinon (oxytocin)

    • Syntometrine (oxytocin + ergometrine)

    • Carboprost (prostaglandin F2)

    • Misoprostol (Prostaglandin E1).

• Surgical measures should be undertaken if there is excessive or continuing bleeding (irrespective of ultrasound findings) eg. balloon tamponade 

In the case of massive secondary PPH, the following should be done simultaneously:

1. Call for help/ initiate massive haemorrhage protocol. 

2. Resuscitation (ABCDE)

3. Monitoring and investigation:

   1. 1. • FBC

         • U&Es

         • CRP

         • Coagulation profile

         • Group and Save sample

         • Blood cultures (if the patient is pyrexial) 

4. Stop the bleeding (with uterotonics/surgical measures, depending on the suspected cause)