Secondary Postpartum Haemorrhage: Incidence, Morbidity and Current Management

Abstract

The authors analyzed 132 women seen consecutively in the years 1996-1998 with secondary postpartum hemorrhage, defined as excessive vaginal blood loss or heavy lochial discharge noted at least 24 hours after the third stage of labor and in the ensuing 6 weeks. Bleeding was considered serious enough to require review by an obstetrician. The incidence during the period under study was 0.8% of women delivering vaginally. The only causative factors identified were a history of primary postpartum bleeding and manual removal of the placenta. Nearly two thirds of women presented 1 to 3 weeks after delivery. All patients were hemodynamically stable when admitted (despite a previous episode of severe shock in one instance). Nearly half the women had uterine tenderness and approximately one fourth were febrile when first seen. Twenty-one women without fever were discharged home on antibiotics. Ten of 74 women evaluated (13.5%) had positive cultures. Twenty-two women received blood transfusions. Fifty-seven women in all were managed conservatively (without uterine evacuation). Twelve of them (21%) subsequently required evacuation. Of 75 women having uterine evacuation at initial admission, 3 (4%) required a repeat procedure. One hysterectomy was necessary, and one patient required uterine packing. Ultrasonography frequently revealed retained placental tissue in the uterine cavity. Three of 85 women having uterine evacuation (3%) experienced uterine perforation. Only five women spent more than a week in hospital. The risk of secondary postpartum hemorrhage is of the same order as lower uterine segment scar rupture in labor; maternal morbidity is significant in both cases.