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Secondary Postpartum Hemorrhage

A secondary postpartum haemorrhage is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks of the postnatal period.

Primary postpartum haemorrhage (PPH) is more common and more dangerous ( Read more abou Primary PPH here . Secondary postpartum hemorrhage occurrs in less than 1% of all births.

While Primary PPH is an acute condition requiring immediate management, the bleeding in secondary PPH is usually not so severe. The patient may complain of spotting on and off for days after her delivery with an occasional gush of fresh blood.

Sometimes, this bleeding may be confused with postpartum lochia, which is a normal discharge after childbirth. It is only when the bleeding continues for days or when it increases in severity or when other symptoms like fever and pain occur that a woman may consult a doctor for help.

Women with pre-existing bleeding disorders such as haemophilia and women taking anticoagulant medicines are at increased risk of PPH. These are somewhat uncommon causes of secondary PPH and will not be described in this page.

Causes of Secondary Postpartum Hemorrhage

Retained Placenta: The commonest cause of secondary pph is retained bits of placenta or membranes in the uterus. Sometimes a part of the placenta may remain attached to the uterine wall. This placental bit can act like a 'foreign body' in the uterus, preventing it from contracting adequately to prevent bleeding. The placental bit can also get infected. Both these factors can cause the woman bleed or spot on and off until the foreign body is expelled. There may also be strong abdominal cramps, as the uterus contracts hard to push out the retained bits of placenta.
Postpartum infection: Postpartum infection can occur either inside the uterus (Endometritis)or in the cervical canal or in the vagina. Sometimes the infection can spread outside the uterus to affect the surrounding tissues like the ovaries, bladder and parametrium. Infections of the breast like breast abscess are also considered a type of postpartum infection but these do not cause secondary PPH. In addition to injuries which occur during the birth process, physiologic changes during pregnancy can contribute to the development of postpartum infections.
Infection of Cervical and Vaginal Tears: Vaginal childbirth is often accompanied by multiple small and large vaginal and cervical tears - inside the cervix, along the edge of the cervix as well as in the vaginal canal. Most of these tears heal without any complications. But some vaginal tears amy be quite large and extend through the perineum right up to the anus. Infection can occur readily in these tears. Sloughing of an infected area can expose a bleeding vessel leading to a sudden gush of fresh bleeding. Spotting on and off or brownish vaginal discharge can also occur from these tears with no major bleeding.

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Puerperal Inversion of Uterus: Uterine inversion, either partial or complete, is an uncommon complication of the third stage of labor. It is usually an acute condition needing immediate emergency management. But a partial inversion may be (a)subacute - over 24 hours and up to the 30th postpartum day or (b) Chronic - more than 30 days after delivery. These can cause secondary postpartum hemorrhage.

Uterine Polyp or Fibroid: A uterine polyp or fibroid can get infected after the delivery and cause secondary hemorrhage. They can also prevent proper involution of the uterus leading to bleeding and pain in the abdomen.

Undiagnosed carcinoma of cervix: A carcinoma of the cervix can go undiagnosed during pregnancy. The blood supply of the cervix is usually increased during pregnancy and the cervix may undergo normal cellular changes. Engorged veins can also occur in the cervix. This can prevent diagnosis of early carcinoma of the cervix. Bleeding or spotting on and off in the postpartum period should always be treated with suspicion and tested for carcinoma.

Chorion-epithelioma: also known as choriocarcinoma, it is a very rare malignant tumor which occurs from the chorion. It usually starts as a hydatidiform mole (molar pregnancy) which transforms into a malignant chriocarcinoma. In almost all cases, this leads to a miscarriage or abortion in early pregnancy. It is extremely rare for chorionepithelioma to follow a normal pregnancy but can occur, especially in twin pregnancy with one healthy baby and one molar pregnancy.

Treatment of Secondary Postpartum Hemorrhage

Treatment of secondary PPH is according to the cause.

Investigations of secondary PPH should include high and low vaginal swabs,blood cultures if fever is present ,full blood count and C-reactive protein. A pelvic ultrasound may help to identify the presence of retained products of conception, although the appearance of the immediate postpartum uterus may not be very reliable.

If products of pregnancy are present, they should be removed under antibiotic cover. There is a great risk of uterine perforation in these cases and the evacuation of the uerus should be carried out only by very competent hands.

It is generally accepted that secondary PPH is often associated with infection and conventional treatment involves antibiotics and medicines to control the bleeding.

Also Read-

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