Late or Secondary Postpartum Hemorrhage



By Dr. Jennifer Markowitz


One week ago 32-year-old Erica gave birth to her third child, following an uneventful pregnancy. Erica has sickle cell anemia, so her doctors monitored her extra closely during the delivery, but there were no problems at that time. Now, one week postpartum, she is experiencing heavy vaginal bleeding; her perineal pads are filling up with blood after only 15 minutes. She begins to feel warm and dizzy, with cramps in her abdomen. Her husband brings her to the emergency room, where her temperature is 101 degrees, her heart rate is 130 and her blood pressure is 87/50. Healthcare providers administer IV fluids and evaluate her for secondary postpartum hemorrhage. A pelvic ultrasound shows that parts of the placenta are retained in Erica’s uterus. Her doctors remove the retained tissue, and the hemorrhage stops.


What Is Postpartum Hemorrhage?


According to the American College of Obstetrics and Gynecology (ACOG), postpartum hemorrhage is defined as 1,000 mL total blood loss or blood loss accompanied by symptoms and signs of low blood volume. (1) Postpartum hemorrhage may be primary or late/secondary. (4) ACOG defines primary postpartum hemorrhage as occurring any time from before the placenta is delivered until 24 hours after the fetus is delivered, or after fetal loss. (1) It is estimated that primary postpartum hemorrhage affects 3% to 5% of women delivering babies. (9) 


What Is Late or Secondary Postpartum Hemorrhage?


Late or secondary postpartum hemorrhage is defined as occurring between 24 hours and 6 weeks postpartum. (4) It is the main reason for readmission to the hospital in postpartum women. (4) However, like primary postpartum hemorrhage, it is rare. (10) According to one study, fewer than 1% of women experience secondary postpartum hemorrhage. (10) In this study, most women had a hemorrhage during the second week after giving birth. (10) Although both types of postpartum hemorrhage are rare, they can have serious complications; together, they result in 12% of maternal deaths in the United States and 25% of maternal deaths worldwide. (9) Nevertheless, postpartum hemorrhage is often preventable. (9) Awareness of the signs and symptoms can help. (9) Women can also talk to their healthcare providers early on about the information in this article.


What Are the Symptoms and Signs of Secondary Postpartum Hemorrhage?


Symptoms of secondary postpartum hemorrhage include:


1. Heavy vaginal bleeding, which may be associated with the passage of large blood clots (4)  It’s important to note that women may not realize that this bleeding is abnormal. (4)


A good rule of thumb is that if perineal pads become saturated with blood after 15 minutes or less, or if blood is pooling beneath the buttocks, immediate medical attention should be sought. (4) If pads are filled within less than 2 hours a woman should also seek medical evaluation. (4)

2. Delayed production of breast milk, which could be associated with retained parts of the placenta and/or fetal membranes. (Normally the whole placenta and the fetal membranes are delivered after the baby is delivered. Sometimes pieces of the placenta and/or fetal membranes stay behind in the uterus, and this can cause various complications.) (2,4)


3. Bad smelling discharge from the uterus (4)


4. Severe abdominal cramps (4)


5. Tender uterus (4)


Signs of secondary postpartum hemorrhage may include:


1. Elevated body temperature (4)


2. Increased heart rate (4)


3. Low blood pressure (4)


What Are Risk Factors for Secondary Postpartum Hemorrhage?


A major risk factor for secondary postpartum hemorrhage is primary postpartum hemorrhage. (4) This may be because a woman who experiences a primary postpartum hemorrhage also has a tendency to bleed at a later time; it may also be because the factors causing the primary postpartum hemorrhage have not resolved completely, resulting in the secondary postpartum hemorrhage. (4, 9)


Risk factors for primary postpartum hemorrhage include: 


1. Antepartum hemorrhage, or hemorrhage prior to delivery (9)


2. Past history or family history of postpartum hemorrhage (4)


3. Maternal anemia (9)


4. Maternal obesity (9)


5. Preeclampsia, or high blood pressure during pregnancy (9)


6. Abnormal location of the placenta (9)


7. Placental abruption, when the placenta separates from the uterus too early before childbirth (5) 


8. Sickle cell anemia (4)


9. Gestational diabetes (4)


10. Disorders of blood clotting (4)


11. Asian or Hispanic ethnicity (4)


12. Primiparity, or first-time pregnancy (9)


13. Multifetal gestation, or pregnancy with multiple fetuses (9)


14. More than 5 past deliveries of living babies (12)


15. Fetal macrosomia, or abnormally large fetus (9)


16. Relaxant anesthetics (12)


17. Polyhydramnios or excessive amniotic fluid (9)


18. Prolonged labor (9)


19. Rapid labor (12)


20. Augmented labor, or labor that is assisted with medication (12)


21. Chorioamnionitis, or infection of the placenta, the membranes within it, and/or the amniotic fluid (8)


22. Uterine fibroids (12)


23. Retained placenta during delivery, requiring manual removal of the placenta (10)


24. Repeated abortion, which increases risk for retained placenta (11)


25. Primary postpartum hemorrhage (5)


26. Maternal age greater than or equal to 35 years (5)


What Causes Secondary Postpartum Hemorrhage?


The most common cause of secondary postpartum hemorrhage is retained parts of the placenta and/or fetal membranes, known as retained products of conception. (11, 4) This can then lead secondarily to a condition known as uterine atony, in which the uterus does not contract normally after delivery, which further contributes to hemorrhage. (4)


Other causes include:


- Infections: Infection of the retained parts of the placenta and/or retained fetal membranes (known as chorioamnionitis) (4, 8)


- Trauma: This may include laceration (cuts or tears) of the vagina, cervix, or uterus. (4) These lacerations can occur spontaneously during the birth process or result from medical interventions (forceps or vacuum-assisted delivery, or from a uterine incision in the course of caesarean section that is placed too low or that is not properly curved). (4) Hemorrhage may also result if wounds from caesarean section do not heal properly, or if they pull apart. (4) Trauma from the birth process may also result in a vaginal hematoma, or blood collection within the soft tissues; this might not develop until several days after a woman gives birth. (4) Vaginal lacerations and hematomas may not be diagnosed at the time of delivery; this is a leading cause of secondary postpartum hemorrhage. (4)


- Uterine artery pseudoaneurysm: This rare cause of secondary postpartum hemorrhage refers to formation of a thin-walled sac in the artery that supplies the uterus, which forms when the artery wall is lacerated and does not heal properly. (3) It happens primarily after traumatic delivery, for example caesarean section, forceps delivery and vacuum extraction, and after manual removal of the placenta. (3)


- Disorder of blood clotting: Rarely, women are born with disorders in which their blood does not clot normally. (9) This predisposes them to postpartum hemorrhage (9). Such disorders can be diagnosed with laboratory tests. (9)



What are the Complications of Secondary Postpartum Hemorrhage?


As mentioned, secondary postpartum hemorrhage is the most common reason for readmission to the hospital after giving birth. (4) One study found that 84% of women with secondary postpartum hemorrhage were readmitted. (10) Other complications include:

Need for surgical treatment (63% of women in this study) (10)

Blood transfusion (17% of women in this study) (10)

Uterine perforation (rare) (10)

Hysterectomy (rare) (10)


How is Secondary Postpartum Hemorrhage Treated?


Women with secondary postpartum hemorrhage should receive IV fluids to restore their blood volume. (9) When postpartum hemorrhage is severe, blood transfusion may be needed. (9) In the most severe cases a massive transfusion protocol may be required, in which clotting proteins are given along with blood. (9) This is because with massive blood loss, blood clotting proteins are also lost. (9)


Treatment of secondary postpartum hemorrhage depends on the cause:


If there are retained parts of the placenta and/or fetal membranes, the retained tissue may be manually removed from the uterus; in some cases a technique called curettage involving an instrument, or other surgical approach, may be needed. (4, 9)


Infection: Antibiotics are given to prevent or treat infection along with medication to promote contraction of the uterus (such as IV oxytocin). (4)


Trauma: Lacerations are sutured (sewn up) and blood collections drained. (9) The drug tranexamic acid may be given to aid clotting. (9)


Disorder of blood clotting: Medication and clotting factors may be given to promote clotting. (4)


Uterine artery pseudoaneurysm: A procedure known as arterial embolization, in which the artery is blocked from within, is 77% successful at treating secondary postpartum hemorrhage due to this cause. (4)


How Can Secondary Postpartum Hemorrhage Be Prevented?


Primary postpartum hemorrhage is a major risk factor for secondary postpartum hemorrhage. (4) It is important to know that primary postpartum hemorrhage is often preventable, by steps such as avoiding routine episiotomy, avoiding delivery with forceps, and active management of the third stage of labor. (4,9) The latter involves providing medication to help the uterus contract, providing controlled traction on the umbilical cord while delivering the placenta, and massaging the uterus to help it contract after delivery. (9)


The Takeaway

Secondary postpartum hemorrhage is a rare and potentially serious disorder. (10,9) Women experiencing secondary postpartum hemorrhage may not initially recognize the symptoms. (4) Education about what constitutes normal and abnormal postpartum bleeding can help. (4) There is reason to be hopeful, as primary postpartum hemorrhage, a major risk factor for secondary postpartum hemorrhage, can often be prevented, and a variety of treatments exist for the causes of secondary postpartum hemorrhage. (9,4) 


References

1. American College of Obstetricians and Gynecologists. “Postpartum hemorrhage. ACOG practice bulletin No. 183.” Obstet Gynecol. October 2017; 130(4): e168-e186.


2. Antonella G, Di Benedetto L, Assorgi C, et al. “Conservative and timely treatment in retained products of conception: a case report of placenta accreta retention.” Int J Clin Exp Pathol. 2015; 8(10): 13625–13629.


3. Boi L, Savastano S, Beghetto M, et al. “Embolization of iatrogenic uterine pseudoaneurysm.” Gyn Min Inv Ther. 2017; 6:85-88.


4. Buettel L. “Secondary postpartum hemorrhage: risk factors, assessment, and intervention.” Am Nurse Today. July 2016; 11(7): 1. 


5. Cleveland Clinic. “Placental Abruption.” Dec 2014. https://my.clevelandclinic.org/health/diseases/9435-placental-abruption


6. Debost-Legrand A, Riviere O, Dossou M, et al. “Risk factors for severe secondary postpartum hemorrhages: a historical cohort study.” Birth. Sep 2015; 42(3): 235-41.


7. Dossou M, Debost-Legrand A, Déchelotte P, et al. “Severe secondary postpartum hemorrhage: a historical cohort.” Birth. Jun 2015;42(2):149-55.


8.Dulay AT. Merck Manual Professional Version. “Chorioamnionitis.” June 2019. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/intra-amniotic-infection


9. Evensen A, Anderson J.M., and Fontaine P. “Postpartum hemorrhage: prevention and treatment.” Am Fam Physician. April 2017; 95(7):442-449.


10. Hoveyda F and MacKenzie IZ. “Secondary postpartum hemorrhage: incidence, morbidity and current management.” BJOG. 2001 Sep; 108(9):927-930.


11. Luo A and Mao P. “Late postpartum hemorrhage due to placental and fetal membrane residuals: experience of two cases.” Clin Exp Obstet Gynecol. 2015; 42(1) 104-5.


12. Moldenhauer J.S. Merck Manual Professional Version. “Postpartum hemorrhage.” June 2018.  https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/postpartum-hemorrhage