Secondary Postpartum Haemorrhage

EDITORIAL COMMENT: This paper provides a useful review of the clinical features and management of secondary postpartum haemorrhage. Table 1A shows comparable statistics from an Australian hospital which the incidence was 2–3 times higher than the 0.5% reported by the authors from their hospital in Hong Kong. Since there are no predictive factors for secondary postpartum haemorrhage the important data concerns proper management. The high incidence of suction evacuation (87%) is noteworthy as was the authors' finding that the procedure stopped the bleeding in all 72 patients requiring this operation. The 1 case of uterine perforation serves as a reminder that the uterus may be soft and friable in these patients. Hysterectomy is seldom required in patients with secondary postpartum haemorrhage but when it is necessary, an experienced surgeon is required, since it is often difficult to secure haemostasis, and ligation of internal iliac arteries may be necessary. The 1 subtotal hysterectomy required in this series was performed before secondary postpartum haemorrhage occurred. The 3 other useful pieces of information provided in this Hong Kong series were that 24% of patients required blood transfusion, that bacteriology although useful on occasions was positive in only 12% of patients, and that histologically proven placental tissue was obtained at suction evacuation in 42% of patients — oedematous decidua is often macroscopically mistaken for placental tissue at the time of surgery in these patients. Summary: Eighty‐three cases of secondary postpartum haemorrhage managed in this teaching unit over a 3‐year period are described. Bleeding occurred most frequently between the 8th and 14th day of the puerperium; 73% of the patients had already been discharged from hospital and required readmission. Suction evacuation was performed in 72 patients and was successful in arresting haemorrhage whether retained placental tissue could be demonstrated on histology or not. There was histological confirmation of retained gestational products in only 30 (42%) of the patients treated surgically. No predictive factors for secondary postpartum haemorrhage could be identified in the obstetric profiles or antenatal course of most of these patients. Patients with retained gestational products could not be distinguished from those without on the basis of history or examination alone apart from 4 patients noted to have incomplete membranes at delivery.