Clinical management and therapy of secondary postpartum hemorrhage

Abstract

Secondary postpartum hemorrhage, defined as excessive bleeding that occurs more than 24 hours after delivery and up to 12 weeks postpartum, occurs in approximately 1% of pregnancies. In the event of secondary hemorrhage, several specific etiologies should be considered. Uterine atony (perhaps secondary to retained products of conception) with or without infection contributes to secondary hemorrhage. Ultrasound evaluation can help identify intrauterine tissue. Endometritis should be strongly suspected in the presence of uterine tenderness and a low-grade fever. Secondary postpartum hemorrhage also may be the first indication of bleeding disorders such as von Willebrand disease. Treatment should be focused on the etiology of the hemorrhage and may include uterotonic agents and antibiotics, but if these fail to resolve the problem or if retained products of conception are suspected, uterine curettage may be necessary. If treating endometritis, broad antibiotic coverage with clindamycin and gentamicin is a common choice, although other combinations also are used. Often the volume of tissue removed by curettage is relatively small yet bleeding usually subsides promptly. Concurrent ultrasound assessment at the time of curettage can help prevent uterine perforation. Patients should be counseled about the possibility of hysterectomy before initiating any operative procedure