[6 MIN READ]

After reading the case with perspective on how to recognize secondary postpartum hemorrhage, it's critical to understand why it occurs and how to treat it.

Etiology of Secondary PPH

Why does secondary PPH occur? The normal physiologic changes associated with pregnancy are the perfect predisposition for an unrecognized hemorrhage. Typically, pregnant women are young and healthy with increases in circulating blood volume and hormonal and vascular changes specific to pregnancy. All of this creates the perfect environment for hemorrhage.

Post-delivery, very specific physiologic changes need to occur for the uterus to involute and the vessels to return to normal.

Uterine myometrial muscle bundles constrict to impede blood flow, and large vessels thrombose to prevent hemorrhage at the detached placental site. Incompetency of either of these processes will result in uterine atony. Normally, the basal portion of the decidua remains after the placenta separates and then divides into two layers: 1) the superficial layer, which is shed; and 2) the deep layer, which regenerates new endometrium. If any of these post-delivery physiologic changes do not take place, the patient is at increased risk for hemorrhage, either primary or secondary. If the patient has previously experienced blood loss from a primary PPH, anemia will already be present and further complicate the issue.

Symptoms of Secondary PPH

Symptoms of secondary postpartum hemorrhage include the following:

• Fever and uterine tenderness if infection is present (typically lower uterine tenderness)
• Hypotension
• Tachycardia
• Tachypnea >22/minute
• Decreased urine output
• Lightheadedness
• Paleness
• Cold and clammy hands and feet
• Syncope
• Anemia (severe anemia is common prior to a secondary hemorrhage)
• Pain may or may not be present
• Occult bleeding
• Sudden bleeding after lochia has tapered off (possibly foul lochia)

Incidence and Associated Conditions

The incidence of secondary hemorrhage is up to 2% of all postpartum women; leading causes are placental retention, subinvolution of the placental bed, and endometritis. Retained placenta and placenta accreta/increta/percreta all pose significant life-threatening risk for hemorrhage. If manual removal of the placenta with a vaginal delivery was required, the patient will be at risk for hemorrhage due to possible retained placenta. Endometritis should be suspected if a woman presents in septic shock post C-section, has prolonged rupture of membranes, multiple vaginal exams, internal monitoring, manual removal of placenta or a prolonged labor. Numerous other less common causes include: fibroids, uterine vascular malformations, choriocarcinoma, undiagnosed cervical carcinoma, dehiscence of a C-section scar, inherited bleeding tendencies, infected polyp and submucosal infection. Worst-case scenarios include those with multiple etiologies such as HELLP syndrome and vaginal laceration, uterine atony with infection, etc. Septic shock may be seen if endometritis is present.

Treatment

Treatment for secondary PPH should use the same guidelines as treatment for primary PPH:

• Achieve hemodynamic stability.
• Know the cause of bleeding.

Knowing the cause will help determine treatment; however, when the source is not known, exam should be immediate to determine a cause for the bleeding. A pelvic exam with an assessment for bleeding that is either visualized or occult should be rapid. Look for abdominal pain, change of mentation and rapidly changing vital signs. Always remember to assess for uterine atony, which is the leading cause of primary PPH.

It is important to recognize that even when no bleeding is visualized, if the clinical picture still fits a picture of blood loss, the assumption should be occult bleeding. Look for the signs that will help confirm occult bleeding such as a rigid abdomen, painful abdomen or bluish discoloration around the umbilicus (this is usually a late sign). While rigid abdomen is a typical telltale sign of occult bleed, fundal height itself may not necessarily reveal a rising uterus depending on the source of the bleed; bleeding could be totally retroperitoneal. Another misnomer is when the fundus palpates firm but the lower uterine segment is actually boggy. Lab values and vital signs may also be borderline stable and cause the clinician to not immediately recognize occult hemorrhage. The clinical picture may not fit a typical hemorrhage scenario, and astute recognition may be needed.

Resuscitation of Secondary Postpartum Hemorrhage

If bleeding is active, stabilize the patient first and follow the primary PPH guidelines; stabilization always takes priority. Balloon tamponade may be required prior to surgery and can help buy time for making the decision for medical vs. surgical management; one study of postpartum hemorrhage reported that 86% of patients who had balloon tamponade did not require any further surgery or procedure to control bleeding.

Call the OB stat team. Insert two large bore IVs and rapidly give crystalloid boluses while determining if medical or surgical management is necessary. Follow massive transfusion protocols if indicated. Consider uterotonic medications, especially if subinvolution of the placental site is suspected (methylergonovine (Methergine), carboprost (Hemabate), and misoprostol (Cytotec)). Uterotonics are typically not helpful with a firm uterus, but subinvolution can be focal; hence, uterotonics may be helpful even when the uterus is firm (not atonic). Overzealous use of uterotonics when the fundus is firm is not recommended.

Surgical intervention is likely. Surgery options include D&C, hysterectomy, and/or embolization; surgical consent should always include the possibility of hysterectomy. If the uterus is atonic or infected, there may be risk for uterine perforation with D&C.

Conservative management includes antibiotics and uterotonics for the stable patient. Clindamycin and gentamycin are the typical antibiotics given for infection.

Risk Factors

Looking retrospectively in searching for explanations, your team debrief reveals numerous high-risk features specific to this case.

Risks for hemorrhage in this patient’s case were: nulliparity, Hispanic ethnicity, augmented labor, prolonged second and third stage labor with increased postpartum bleeding (even though PPH had not been documented in her chart), difficult removal of the placenta, and lack of breastfeeding (known to decrease uterine size and control bleeding). Estimated blood loss was reported, while quantitative blood loss was not. The team discussed that estimated blood loss is typically grossly underestimated, which was most likely true in this case. The patient probably did have primary PPH at delivery, which then placed her at risk for secondary PPH. Recall that in a young healthy woman, one liter of blood can be lost before any change of vital signs are witnessed, which is what occurred in this case. This patient’s vital signs and lab values were borderline normal (she had a low-grade fever, low BP, and anemia at time of onset) and did not bring attention to any suspect pathophysiology until frank deterioration. In retrospect, borderline values for both the labs and the vital signs may have helped to predict the clinical picture. Heightened surveillance should have been implemented. The surgeon immediately recognized the occult bleed and the OB team moved swiftly to get the patient to the OR; it proved life-saving.

Team Debrief

The team debrief included learning points for understanding secondary PPH and what to look for in future cases. Secondary PPH (especially if occult) can be tricky to diagnose with nebulous signs and symptoms that require sharp clinician skills and team assistance.

Important considerations for all secondary PPH cases:

• Duration of rupture of membranes
• Length of labor
• Labor augmentation
• Diagnosis of chorioamnionitis
• Placental issues (retention, morbidly adherent placenta)
• Risk factors for hemorrhage

Think about and look for signs and symptoms of infection.

• Review recent lab values. Is there an elevated white count? Anemia? HELLP syndrome?
• Inspect the placenta. Is it intact? Is there odor or discoloration?
• What were details of the delivery? Was there manual removal of placenta?
• Is there anything in the patient’s history that would predispose her to bleeding tendencies? Did she take platelet inhibitors or anticoagulants? Could she have Von Willebrand disease?

In this very difficult case, the patient survived due to the skilled care and brilliance of the OB team. As AIM (Alliance for Innovation on Maternal Health) has taught us, “Readiness, Recognition, and Response” save lives. Use a standardized team approach to manage all postpartum hemorrhage cases; know your facility’s staged postpartum hemorrhage protocols; have the ability to rapidly escalate care and generate a rapid team response; and use massive transfusion protocols when needed. Be a critical thinker. Be ready. Save a life.

Resources

• ACOG Practice Bulletin #183. Postpartum Hemorrhage. October 2017.
• Angelini, D. La Fontaine, D. Eds. Obstetric Triage and Emergency Care Protocols 2^nd Edition. Springer Publishing. New York, 2017.
• Berens, P. Overview of the postpartum period: Physiology, complications, and maternal care. UpToDate. January 2019.
• Belfort, M. Overview of postpartum hemorrhage. UpToDate. October 2018.
• Belfort, M. Secondary postpartum hemorrhage. UpToDate. October 2018.
• CMQCC. Postpartum hemorrhage toolkit. March 2015.
• Dossou M. et al. Secondary (late) postpartum hemorrhage. Birth. 2015;42(2):149.