Obstetrics & Gynaecology
A 34 year old woman is brought to the Emergency Department with postpartum bleeding 48 hours following a home delivery. She has no past medical history. You suspect a secondary postpartum haemorrhage. What is the most common cause of secondary postpartum haemorrhage?
Answer:
The two most common causes are endometritis and retained products of conception.Postpartum Haemorrhage
Obstetrics & Gynaecology
Last Updated: 6th September 2022
Definitions
- Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. PPH can be minor (500–1000 ml) or major (more than 1000 ml).
- Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally.
Risk factors
Risk factors for PPH may present antenatally or intrapartum; care plans must be modified as and when risk factors arise. Women with known risk factors for PPH should only be delivered in a hospital with a blood bank on site. The most common cause of PPH is uterine atony.
Risk factors:
- Multiple pregnancy
- Previous PPH
- Pre-eclampsia
- Fetal macrosomia
- Failure to progress in second stage
- Prolonged third stage of labour
- Retained placenta
- Placenta accreta
- Episiotomy
- Perineal laceration
- General anaesthesia
Prophylactic uterotonics should be routinely offered in the management of the third stage of labour in all women as they reduce the risk of PPH.
Immediate management of major postpartum haemorrhage
Major PPH = blood loss greater than 1000 ml and continuing to bleed or clinical shock.
Clinicians should be aware that the visual estimation of peripartum blood loss is inaccurate and that clinical signs and symptoms should be included in the assessment of PPH. However, clinicians should also be aware that the physiological increase in circulating blood volume during pregnancy means that the signs of hypovolaemic shock become less sensitive in pregnancy. In pregnancy, pulse and blood pressure are usually maintained in the normal range until blood loss exceeds 1000 ml; tachycardia, tachypnoea and a slight recordable fall in systolic blood pressure occur with blood loss of 1000–1500 ml. A systolic blood pressure below 80 mmHg, associated with worsening tachycardia, tachypnoea and altered mental state, usually indicates a PPH in excess of 1500 ml.
- Resuscitation
- Call for help
- Position the patient flat
- Keep the woman warm using appropriate available measures
- Give high-flow oxygen
- 2 x large intravenous access
- Baseline bloods (FBC, U&Es, LFTs, coagulation screen) and cross-match (4 units minimum)
- Transfuse blood as soon as possible; major obstetric haemorrhage protocols must include the provision of emergency blood with immediate issue of group O, rhesus D (RhD)‐negative and K‐negative units, with a switch to group‐specific blood as soon as feasible.
- If clinically required; until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed isotonic crystalloid. Further fluid resuscitation can continue with additional isotonic crystalloid or colloid (succinylated gelatin).
- Consider other blood products:
- If no haemostatic results are available and bleeding is continuing, then, after 4 units of red blood cells, FFP should be infused at a dose of 12–15 ml/kg until haemostatic test results are known.
- If prothrombin time/activated partial thromboplastin time is more than 1.5 times normal and haemorrhage is ongoing, volumes of FFP in excess of 15 ml/kg are likely to be needed to correct coagulopathy.
- Administer 2 pools of cryoprecipitate if haemorrhage is ongoing and fibrinogen less than 2 g/l.
- Administer 1 pool of platelets if haemorrhage is ongoing and platelet count less than 75 × 109/l.
- Assess measured or estimated blood loss
- Assess cause
- Tone (uterine atony)
- Tissue (retention of placental tissue)
- Trauma (vaginal or cervical tears, uterine rupture)
- Thrombin (coagulopathies and vascular abnormalities)
- Stop the bleeding
- Bimanual uterine compression
- Ensure bladder is empty (urinary catheter)
- Drugs
- Oxytocin 5 units slow IV
- Ergometrine 500 micrograms slow IV or IM
- Tranexamic acid 1 g slow IV (give early)
- Oxytocin infusion 40 units in 500 ml isotonic crystalloids at 125 ml/hour
- Carboprost 250 micrograms IM every 15 minutes, up to 8 doses
- Misoprostol 800 micrograms SL
- Repair perineal/vaginal/cervical tears
- Continuous assessment
- Chart observations
- Continue to assess blood loss
- Accurate fluid balance
- Reassess causes of bleeding
- 2nd dose of tranexamic acid 1g slow IV, 30 mins after 1st dose if PPH persists
- Consider surgical interventions if pharmacological measures fail to control the haemorrhage; intrauterine balloon tamponade is an appropriate first‐line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage.
Secondary postpartum haemorrhage
The causes of secondary PPH are numerous and include endometritis (uterine infection), retained products of conception (RPOC) and subinvolution of the placental implantation site.
The main symptom of secondary postpartum haemorrhage is excessive vaginal bleeding. The patient may complain of spotting on-and-off for days after her delivery, with an occasional gush of fresh blood. However, approximately 10% of cases will present with massive haemorrhage – and this can quickly lead to hypovolemic shock. Additional clinical features will depend on the underlying cause. For example, women with endometritis may also present with fever/rigors, lower abdominal pain or foul smelling lochia. On abdominal examination, the patient may complain of lower abdominal tenderness (usually a sign of endometritis), or the uterus may still be high (sign of retained placenta).
The management of women presenting with secondary PPH should include an assessment of their haemodynamic status, an assessment of the blood loss and an evaluation of the woman's concerns (for example, is her bleeding becoming inconvenient because it has persisted longer than she had expected?). An assessment of vaginal microbiology should be performed (high vaginal and endocervical swabs). A pelvic ultrasound may help to exclude the presence of retained products of conception, although the diagnosis of retained products is unreliable.
The mainstay of treatment in secondary PPH is with antibiotics and uterotonics:
- 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. N.B. antibiotic regimes will differ according to local hospital trust antimicrobial guidelines.
- Uterotonics – examples include syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1).
Surgical measures should be undertaken if there is excessive or continuing bleeding (irrespective of ultrasound findings). In continuing haemorrhage, insertion of a balloon catheter into the uterus may be effective. N.B. Any surgical evacuation of retained products of conception carries a high risk of uterine perforation (as the uterus is softer and thinner post-partum). It should involve a senior obstetrician in the planning and delivery of surgery.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
