©Pregnancy bliss 2008
Postpartum hemorrhage (PPH)
Delayed (secondary) postpartum hemorrhage (PPH)
Heavy vaginal bleeding occurring more than 24 hours after delivery affects around 1 in a 100 (1%) of all new mothers. The technical term is secondary PPH (postpartum hemorrhage). It may occur any time in the first six weeks following delivery, but is most common between the first and second week. Secondary PPH after the first four weeks is quite uncommon.
Causes of secondary postpartum haemorrhage
It is not always possible to identify the cause of secondary PPH.
The two known causes are:
Retained products of conception where some bits of placenta or membranes are not expelled
Infection of the lining of the womb.
Retained products of conception after delivery
The problem of retained placental tissue and/or membranes is less common than one may be tempted to believe. When an ultrasound scan of the pelvis is done after a woman presents with secondary PPH, an image obtained will show contents suggestive of possible placental tissues. Unfortunately, the scan will not be able to distinguish simple blood clots from placental tissue. Experience shows that this tends to turn out to be clots.
Because of this, many obstetricians regard ultrasound in a person with symptoms of
secondary PPH to be an ill-
Secondary postpartum haemorrhage (PPH) caused by infection
When there is infection affecting the lining of the womb, there are usually clinical features that may point towards this possibility. These features may include pelvic pain, fever and general malaise. Then again, these may be completely absent.
Tests are usually done, including a blood count and vaginal swabs to look for the culprit bacteria. These may be inconclusive. In fact, the value of taking vaginal swabs in a woman who is bleeding from the uterus is doubtful. Many experts argue that if one really wants to identify the infection, swabs have to be taken from high up in the womb itself. This is usually an impractical option, unless the woman is being taken to theatre for evacuation of the uterus.
Treating secondary postpartum hemorrhage
A clinical judgment has to be made according to each individual's case. The management may include some or all of these:
Bed rest
Oxytocic drugs to promote uterine contraction,
Antibiotics,
Uterine exploration for retained products and
Blood transfusion. This is rarely required in secondary PPH.
Evacuation of the uterus in secondary PPH
Like in all cases, faced with secondary PPH, the doctor has a duty to ensure no unnecessary surgical procedures are undertaken. Evacuation may actually aggravate the bleeding by dislodging the fragile clot plugs in the multiple potential bleeding points in the uterus. One needs to think carefully before embarking upon this. It is not always an easy decision.
Hysterectomy as a result of secondary PPH
When all conservative means of controlling the bleeding fail, the attending obstetrician
may be left with no choice but to carry out a hysterectomy as a life-