Secondary postpartum haemorrhage in a tertiary care hospital of North India: a retrospective analysis

Abstract

Background: Postpartum haemorrhage (PPH) is a very common complication that follows delivery. It is one of the leading causes of maternal mortality both in developing and developed countries. Primary PPH has been studied a lot, but data regarding secondary PPH is sparse. Our objective was to study the clinical characteristics and outcome of patients presenting with secondary PPHMethods: A retrospective descriptive study done at Lalla Ded hospital Srinagar, a tertiary care hospital of North India, between June 2015 and December 2015.Results: Fifty patients with secondary PPH were studied out of whom 36 were delivered outside this hospital and referred. Fourteen patients who delivered in this hospital developed secondary PPH. Mean age of patients was 35±3 years. Retained products of contraception (RPOCs) was the leading cause in 36 (72%) of patients followed by endometritis in ten (20%). Mean hemoglobin concentration was 8.7±1.9grams ranging from 4.4 grams to 12.9 grams. Mean hospital stay was 6.3±1.5 days ranging from 1 day to 20 days. Curettage was done in 40 (80%) of patients including 36 having RPOC s and check curettage in four patients. Fourteen (28%) patients required blood transfusion. One patient required hysterectomy. None of the patients died.Conclusions: Secondary PPH has been studied very little. Our results show retained products of contraception as a leading cause of secondary PPH which is probably related to poor management of third stage of labour. There is crucial role of active management of third stage of labour in preventing secondary PPH. Majority of secondary PPH patients require dilatation and curettage with other supportive measures only. Surgical intervention is rarely required. Blood loss is usually mild to moderate. Prognosis is good if medical intervention is sought early.

Secondary Postpartum Haemorrhage following vaginal delivery — a 3-year survey of causes and management

“…This difference may be related to AL-Yarmok's status as a teaching hospital and tertiary centre that receives referral cases from all areas in our country. The time interval between delivery and onset of secondary PPH was 6-10 days for 44.5% of patients, which is similar to the finding published by Waseeqa Nigeen [16]. A history of primary PPH among women with secondary PPH in our current work was 45.5%, higher than the value cited by Dossou M et al (19%), and it has been suggested that immediate PPH is a predictive factor of hysterectomy (4).…”

“…Fever was the most common symptom that led patients to seek medical advice and it was present in 159 (79%) of cases. This finding does not agree with the study done by Waseeqa Nigeen et al [16]; 2017 in which he found that only fourteen (28%) of patients had a fever. This variation may be due to most of the patients not taking antibiotics even if needed after vaginal deliveries, increasing the incidence of endometritis; it is well known that fever is one of the symptoms that indicate infection.…”

Hysteroscopy to identify retained placental tissue and excision in secondary post-partum haemorrhage

“…15,16 Eight patients (0.15%) who had delivered by caesarean section, developed secondary PPH, while six (0.26%) of patients who delivered vaginally developed secondary PPH. 11 In this study, four of the five cases of secondary PPH were following caesarean delivery. Retained products are not uncommon after caesarean because various factors could be operative, like localized adherent placental products, deep cornua of the uterus as an anatomical variation, previous scars on the uterus where the membranes may not easily peel off during placental removal and most importantly, in a caesarean delivery, it is not a physiologic separation and placental expulsion as in vaginal delivery, it is more like placental removal with hand, hence chances of incomplete removal is possible.…”

“…3 Retained products of conception (RPOCs) was the leading cause in 36 (72%) of patients, curettage was done in 40 (80%) of patients including 36 having RPOCs and check curettage in four patients. 11 RPOCs was documented as the most common cause of secondary PPH. 12,13 Among 33 cases of secondary PPH, most common causes found were, retained bits of placenta in 11 (34%) patients, 27% uterine wound dehiscence, 24% retained clots and 15% endometritis.…”

Study of Factors Associated With Haemodynamic Changes Around Puerperium

“…3,4 India has a maternal mortality ratio of 167/1,00,000 livebirths. 5,6,7 Leading causes of maternal mortality and morbidity in our country are postpartum haemorrhage and underlying anaemia (25-30%). 8 The current standard practice of postpartum blood loss assessment is visual estimation by a healthcare provider who looks grossly at the blood lost during delivery and makes a quantitative estimate.…”