Would one be justified in saying that, in secondary PPH, evacuating the uterus is not a means of first resort?
Absolutely. The clinician has a duty to ensure no unnecessary surgical procedures are carried out. Evacuation may actually aggravate the bleeding by dislodging the fragile clot plugs in the multiple potential bleeding points in the uterus. It is not always an easy decision.
Is there any possibility that secondary PPH can lead to loss of the uterus (hysterectomy)?
Yes, but this is a very remote possibility. When all conservative means of controlling the bleeding fail, the attending obstetrician may be left with no choice but to carry out a hysterectomy as a life-saving procedure. Emphasis has to be put on the fact that, in secondary PPH, this is very rare indeed.
Infection risk post-delivery (Puerperal sepsis)
Are there any predisposing factors to developing womb infection, post delivery?
Again, in most cases, there is no obvious predisposing factor. Occasionally such factors as prolonged labour, chronic undernutrition, anaemia or a weakened body immunity may be identifiable.
Occasionally the "flesh-eating bug" has been reported to cause postpartum infection. How common is this frightening occurrence?
This is very rare. However, when it occurs, especially if there is delay in diagnosis, it can be deadly.
When it occurs, it usually follows caesarean section. There is slowly advancing soft tissue infection. There may be extensive tissue destruction. Treatment will involve surgical removal of this tissue as well as a very aggressive antibiotic course in high doses. Fortunately, the offending bacteria (group A beta-haemolytic streptococci) respond well to antibiotics. The medical term for the condition is "necrotizing fasciitis”. Sometimes other types of bacteria are to blame.
Would you say a caesarean section increases the risk of puerperal infection?
There is no doubt about this. Infection following caesarean section, especially emergency ones, is definitely more common than following vaginal delivery. This is the case regardless of whether we are talking about womb infection, pelvic infection or urinary tract infection. This is one reason among others why unnecessary caesarean sections should be actively avoided.
The risk of infection following caesarean section can be reduced by administering preventative antibiotics just before the operation. These are given intravenously. There is no place for oral antibiotics.
How common is pelvic abscess formation?
It is rare. Again, it is relatively more common after caesarean section when compared to vaginal delivery.
The abscess needs draining as the main form of treatment. This may be complemented with antibiotics for several days.
Can a puerperal pelvic abscess have long-term consequences?
Yes. This may be in the form of problems with future fertility and/or chronic pelvic pain. This is not because of failure to eradicate the infection but the aftermath of the infection, in the form of scarring and adhesions which may affect the free passage of the tubes. Such consequences are not common.