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Definition
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Secondary post partum haemorrhage is defined as excessive blood loss from the genital tract occurring more than 24 hours to 6 weeks after delivery.
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Aetiology
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- Retained products of conception
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- Infection (often secondary to retained products)
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- Lacerations, including episiotomy
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- Others (rare): Blood dyscrasias, Trophoblastic disease, Carcinoma of the cervix, Submucous fibroids (causing subinvolution), Placental site subinvolution
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Management
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1. Assess patient
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The diagnosis and management of a secondary post-partum haemorrhage primarily relies on clinical assessment. Ultrasound, looking for retained products of conception, should play a minor secondary role, as it has a high false positive rate (low specificity) which may lead to unnecessary aggressive intervention with a significant risk of serious consequences. Ultrasound does not easily differentiate between retained products and blood clot.
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- Estimate the total blood loss and measure Hb.
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- Vital signs: temperature, pulse and blood pressure.
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- Check status of cervical os and take an endocervical swab.
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- Consider B subunit HCG testing to exclude trophoblastic disease.
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2. Treat the Cause
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General principles of treatment
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- Bed rest and intravenous antibiotic therapy are the mainstays of treatment.
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- Curettage is not performed routinely (risk of uterine perforation or Asherman's Syndrome). Evidence of retained products is suggested by subinvolution of the uterus, an open cervical os or ultrasound findings.
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- Oxytocics (eg: oral Ergometrine) have almost no part in the management.
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- If vaginal bleeding continues following curettage for secondary post partum haemorrhage, then consider the need for a pelvic trans-vaginal ultrasound scan.
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Retained products of conception
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Bleeding in the first few days after delivery is probably due to retained products of conception. Gentle digital evacuation of the uterus under general anaesthesia should be performed. Antibiotic therapy is indicated prior to the procedure to reduce the risk of Asherman's Syndrome.
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Uterine infection
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Bleeding occurring later in the puerperium may be due to infection of the uterus, for which antibiotics should be prescribed. If bleeding continues despite antibiotics exploration of the uterus is indicated.
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