Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate

Abstract

Objectives To evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery. Materials and methods This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital between January 2004 and June 2018. Descriptive statistics and the chi-square test were used for data analysis. Results The incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization. Conclusions Endometritis was the most common cause of secondary postpartum hemorrhage. Women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

Vascular Subinvolution of the Placental Implantation Site as the Cause of Hysterectomy

“…Detection of extravillous cytotrophoblastic cells with helpful markers as immunostaining positivity for keratin AE1/AE3 profile provides the information for the direct diagnosis of vascular subinvolution. 6 The management of vascular subinvolution is controversial and includes conservative management such as vaginal packing and uterotonic drugs and more aggressive treatments with embolotherapy and hysterectomy. 15…”

“…Extravillous interstitial and/or endovascular trophoblastic cells should also be recognized. 6 Elastin stains (elastic von Gieson or elastochrome) can be useful in characterizing the vessel wall anatomy. Finding of extravillous cytotrophoblastic cells in the wall of vessels can confirm the vascular subinvolution.…”

“…4,5 Vascular subinvolution of the placental implantation site refers to delayed or incomplete physiologic vascular closure at the placental attachment site. 6 Vascular subinvolution has almost always been misdiagnosed by physicians. The diagnosis of vascular subinvolution is often confirmed after hysterectomy and there are no practical clinical factors and rare radiologic clues related to its early diagnosis.…”

The Histological Spectrum Reported on Evacuated Endometrial Tissue From Patients With Secondary Postpartum Hemorrhage: A Pilot Study

“…Among the 123 women identified over 14 years in a tertiary care hospital in Thailand [ 15 ], a uterine evacuation was undertaken in 36 (29.63%). The authors point out that subinvolution of the placental bed-a possible cause of SPPH-was not diagnosed in either the eight hysterectomy specimens managed along the line or the 36 specimens evacuated from the endo-uterine cavity.…”

Frequency and Clinical Outcomes of Women with Postpartum Hemorrhage at a Tertiary Care Hospital

“…PPH management includes multiple blood transfusion associated complications such as bladder injury, respiratory distress, uterine packing, and sepsis during postpartum hysterectomy [7]. The higher prevalence of PPH is mainly due to lack of knowledge regarding antenatal screening significance in high risk patients and childbirth at home by unqualified birth attendants in developing countries [8]. Majority of complications associated with pregnancy and childbirth in Pakistan are caused by lack of intrapartum care and skilled antenatal during labor contributing to maternal and fetal loss [9].…”