Article Title: Medical management of secondary postpartum haemorrhage: A prospective cohort study

Authors: Rachael Fox, et al.

Article Link (see pdf below): https://pubmed.ncbi.nlm.nih.gov/35699126/

The reason I chose this article is that during rotation, I saw a patient presenting to L&D triage complaining of heavy vaginal bleeding and abdominal pain about 4 weeks after an NSVD. Primary postpartum haemorrhage (PPH) occurs within 24 hours, with causes being the mnemonic as the “4 T’s”, which are Tone, Trauma, Tissue, Thrombin. Secondary PPH occurs between 24 hours and 12 weeks post-delivery, with other causes such as retained products of conception (RPOC), endometritis, and subinvolution of the uterus to name a few, thus having different management compared to primary PPH.

This article evaluates the efficacy of medical management for secondary PPH.  The authors conducted a prospective cohort study involving 120 patients who underwent primary medical management for secondary PPH. 92 (82%) were managed successfully with medical management, and 22 (18%) required surgery. Medical management involved misoprostol (n = 33), antibiotics (n = 108), and less commonly other uterotonics like syntocinon or ergometrine (n = 6). Factors associated with lower rates of successful medical management includes manual removal of the placenta, vaginal birth, RPOC on US, and primary PPH ≥ 500 mL. 

Overall, this article shows that non-surgical management primarily with antibiotics ± misoprostol is effective in the majority (82%) of secondary postpartum hemorrhage cases, allowing most patients to avoid surgery. Certain clinical factors (e.g., RPOC on ultrasound, higher bleeding volume, and later postpartum presentation) may help predict which patients are more likely to require surgical intervention.

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