QuestionSBA
QuestionChoice
Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.
50018
b
Retained products of conception
QuestionChoice
Whilst the scenario suggests this woman had a perineal tear that required suturing, this is a less likely cause for secondary postpartum haemorrhage. Perineal tears can become infected, however would be unlikely to cause abdominal pain and nausea.
50019
c
Perineal infection
QuestionChoice
Abnormal involution of the placental site is a rare cause of secondary postpartum haemorrhage and describes the abnormal persistence of patent spiral arteries following delivery. This can present with profuse secondary postpartum haemorrhage.
50021
e
Abnormal involution of the placental site
QuestionChoice
Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.
50020
d
Normal lochia
QuestionChoice
Endometritis is the most common cause of secondary postpartum haemorrhage, and typically presents between 2 and 10 days postpartum
50017
a
Endometritis
QuestionComment
wouldn't the absence of fever rule out endometritis? I would have thought retained products of conception would be more likely
16465
QuestionComment
high WCC

25121
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Kinase Power
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Fever Metabolism
QuestionComment
I thought it would be RPOC causing endometritis? Couldn’t this be the case?
52080
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subscriber
Chronic Bradykinin
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Chapter
# Summary

Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery. The primary causes are uterine atony, birth canal injury or tear, retained placental or foetal tissue, and coagulopathies. Risk factors include a previous PPH, high BMI, multiple pregnancies, advanced maternal age, and more. Initial management involves resuscitation with an ABCDE approach and potentially activating a major haemorrhage protocol. Further management strategies may include rubbing the uterus, medication, or surgical treatment. Secondary PPH refers to bleeding from 24 hours to 12 weeks postpartum, typically caused by retained products of conception or endometritis. 


# Definition



Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery.


# Aetiology


The aetiology of postpartum haemorrhage (PPH) can be remembered using the mnemonic of the 4 'T's: 

- Tone: The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.

- Trauma: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries.

- Tissue: Retained placental or foetal tissue can cause continued bleeding.

- Thrombin: Coagulopathies can lead to continued bleeding due to a failure of clotting.

# Risk Factors

Risk factors for postpartum haemorrhage (PPH) include:

- PPH in previous pregnancy
- BMI >35
- Multiple pregnancy
- Parity >4
- Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia
- Delivery via Caesarean section
- Induction of labour
- Instrumented delivery (forceps or ventouse) and episiotomy
- Prolonged labour (greater than 12 hours)
- Macrosomia (>4kg baby)
- Advanced maternal age


# Investigations


Investigations for PPH include blood tests for Group/Save and Crossmatch, and consideration of fresh frozen plasma if clotting abnormalities are present. In cases of secondary PPH, ultrasound looking for retained products and endocervical/high vaginal swabs looking for infection are recommended.

# Management


Initial management of PPH involves:

- Resuscitation with an ABCDE approach
- Consideration of activation of a major haemorrhage protocol
- Laying the woman flat 
- Inserting two large bore cannulas
- Providing oxygen
- Considering fresh frozen plasma if clotting abnormalities are present

Further management strategies may include:

- Mechanical methods such as rubbing the uterus and catheterisation
- Medical treatments including oxytocin, syntocinon, ergometrine, carboprost, misoprostol, and tranexamic acid
- Surgical treatments such as intrauterine balloon tamponade, B-lynch suture around the uterus, uterine artery ligation, or hysterectomy 

For secondary PPH, management depends on the cause and can include surgical evacuation for retained products of conception or antibiotics for infection.

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Postpartum haemorrhage
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Obstetrics
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Concept
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Postpartum haemorrhage
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Quesmed Tutorial: Obstetric Emergencies
Endometritis
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A 25-year-old woman, eight days postpartum after an uncomplicated vaginal delivery, presents with lower abdominal pain, heavy lochia (using 1-2 pads/hour), and nausea, expressing concern about the thickness of her discharge.



On examination, her abdomen is soft, uterus normally involuted, with tenderness in the lower abdomen.




A gentle speculum examination reveals copious thick bloody discharge, with an offensive smell.



Her observations are: heart rate 122 bpm, blood pressure 110/76 mmHg, respiratory rate 16 breaths/min, oxygen saturation 100% on room air, and temperature 37.1°C.  



Her full blood count test results are as follows:



||||
|--------------|:-------:|---------------|
|Haemoglobin|79 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|402x10<sup>9</sup>/L|150 - 400|




What is the most likely source of her vaginal bleeding?
a