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Pregnancy Bliss | Reproductive Health Hub

Often times, post-partum haemorrhage (PPH) requires emergency blood transfusion

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What if the pelvic haematoma is progressive?

If the haematoma appears to be getting bigger, with evidence from serial - usually daily - ultrasound scans and/or falling blood count (haemoglobin), then there is no choice but to perform an operation to stop this. A laparotomy (where the abdomen is opened) will be performed and the clot evacuated. The bleeding points are sought and secured. It is a major operation which will prolong the new mother's hospital stay for probably four to seven days.    



Postpartum haemorrhage (PPH)


How common is delayed postpartum haemorrhage (PPH)?

Significantly heavy bleeding occurring more than 24 hours after delivery affects around 1 per cent of all new mothers. The technical term is secondary PPH (postpartum haemorrhage). It may occur any time in the first six weeks following delivery, but is most common between the first and second week. Secondary PPH after the first four weeks is quite uncommon.PPH may require blood transfusion



What causes secondary postpartum haemorrhage?

The cause is not always identifiable.

The two known causes are:

Retained products of conception where some bits of placenta or membranes are not expelled

Infection of the lining of the womb.



How common is the problem of retained products after delivery?

It is less common than one may be tempted to imagine. In fact, a lot of cases purported to be retained products following ultrasound scan turn out not to be this. Following this apparent diagnosis, evacuation of the uterine contents is done and, as it turns out in many cases, only clots are retrieved. Because of this, many obstetricians regard ultrasound in a person with symptoms of secondary PPH to be an ill-advised venture, since it is likely to lead to a uterine evacuation procedure, mostly under a general anaesthetic, which in many cases turns out to be unnecessary.







How will one recognize secondary postpartum haemorrhage (PPH) caused by infection?

There are usually clinical features that may point towards this possibility. These may include pelvic pain, fever and general malaise. Then again, these may be completely absent.

Tests are usually done, including a blood count and vaginal swabs to look for the culprit bacteria. These may be inconclusive. In fact, the value of taking vaginal swabs in a woman who is bleeding from the uterus is doubtful. Many experts argue that if one really wants to identify the infection, swabs have to be taken from high up in the womb itself. This is usually an impractical option, unless the woman is being taken to theatre for evacuation of the uterus.



So, how does one go about managing secondary postpartum haemorrhage where there is no readily identifiable cause?

A clinical judgement has to be made according to each individual's case. The management may include some or all of these:

Bed rest

Oxytocic drugs to promote uterine contraction,

Antibiotics,

Uterine exploration for retained products and

Blood transfusion.

Transfusion is mentioned here but in fact it is rarely required in secondary PPH.





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