Secondary Postpartum Hemorrhage (Secondary PPH)

Definition

• Blood loss causing hemodynamic instability, or
• A 10% drop in hematocrit, or
• Requirement for packed red blood cell transfusion

Incidence: approximately 1–2% of all postpartum women.

Causes ("4 T's" framework applied to secondary PPH)

• Uterine vascular malformations (arteriovenous malformations)
• Submucosal fibroids / infected polyp
• Choriocarcinoma
• Undiagnosed cervical carcinoma
• Placenta accreta spectrum (accreta/increta/percreta) — retained morbidly adherent placenta

Clinical Features

• Heavy vaginal bleeding (24 hrs – 12 weeks postpartum)
• Uterine tenderness / subinvolution (uterus larger and softer than expected for the postpartum stage)
• Fever and offensive lochia if infective cause
• Signs of hypovolemic shock in severe cases (tachycardia, hypotension, altered mentation)

Key point: Hematologic adaptations of pregnancy (plasma volume +40%, RBC volume +25%) can mask signs of hemorrhage. Up to 30% blood volume loss may occur before blood pressure drops.

Investigations

Management

Step 1: Resuscitation

• Call for senior help immediately
• High-flow O₂ via face mask
• 2 large-bore IV access lines
• IV crystalloid (lactated Ringer's); prepare for blood product transfusion
• Monitor vital signs closely (pulse is the first sign to change)
• Foley catheter to monitor urine output

Step 2: Identify and Treat the Cause

A. Retained Products of Conception

• Uterotonics (first-line medical):
  • Oxytocin: 20–30 units in 1 L IV fluid (infusion rate ≤100 mU/min); avoid IV bolus (risk of hypotension)
  • Methylergonovine (Methergine): 0.2 mg IM every 2–4 hours; contraindicated in hypertensive disorders (causes vasoconstriction → severe hypertension)
  • Carboprost (15-methyl PGF₂α, Hemabate): 250 μg IM, repeat every 15–90 min (max 8 doses); use with caution in asthma/cardiovascular disease
  • Misoprostol: 800–1000 μg rectally/transvaginally (intrauterine route reported) — useful when conventional pharmacotherapy fails
• Surgical evacuation: Suction curettage / ERPC (evacuation of retained products of conception) under ultrasound guidance

B. Infection / Endometritis

• Broad-spectrum antibiotics (e.g., clindamycin + gentamicin ± metronidazole)
• If retained products co-exist, evacuate after antibiotic cover

C. Subinvolution of Placental Site

• Uterotonics as above
• Uterine massage (bimanual compression if needed)

D. Coagulopathy

• Fresh frozen plasma (FFP), cryoprecipitate, platelet transfusion as appropriate
• Tranexamic acid (TXA) — antifibrinolytic; increasingly used, evidence from WOMAN trial extends to secondary hemorrhage
• Target fibrinogen >2 g/L

Step 3: If Hemorrhage Continues Despite Medical Management

• Uterine balloon tamponade: Bakri balloon or large Foley catheter balloon (especially for low placental site bleeding)
• Uterine cavity packing with sterile gauze
• Selective uterine artery embolization (UAE): preferred in hemodynamically stable patients where angiography suite is available — fertility-sparing
• Laparotomy options (stepwise):
  1. Uterine/B-Lynch compression sutures
  2. Uterine artery ligation (O'Leary sutures)
  3. Internal iliac artery ligation
  4. Peripartum hysterectomy — last resort, definitive

Differential Diagnosis

Key Points Summary

1. Secondary PPH = haemorrhage >24 hours to 12 weeks postpartum
2. Most common causes: retained products, subinvolution, endometritis
3. First-line management: resuscitate → uterotonics → evacuate retained tissue → treat infection
4. Methylergonovine is contraindicated in hypertensive disorders
5. Surgical escalation follows a stepwise approach; hysterectomy is the definitive last resort
6. Always rule out gestational trophoblastic disease with serum β-hCG if presentation is atypical
7. Women with von Willebrand disease are at particular risk for recurrent secondary PPH