Objectives: To determine the various factor associated with secondary PPH and to evaluate the medical or surgical intervention needed in secondary PPH.

Methods: The study was a hospital based, carried out in a tertiary hospital of Manipur, Regional Institute of Medical Sciences, Imphal. It was a prospective longitudinal study. It was conducted during the period of November 2014 to April 2016. Sixty five women with bleeding per vagina with a diagnosis of secondary postpartum haemorrhage and subsequently getting admitted during the study period were included in the study.

Results: In the study conducted, the majority of women were in the age group of 20-30 year (63.1%).The mean age was 27.±6.04. Parity in the present study did not influence the incidence of secondary PPH, and the distribution of its causes was the same in both primiparous and multiparous women. In 17(26.2%) secondary PPH presented less than 7 days of delivery, 24(36.9%) within 8-14 days, 14(21.5%) within 15-21 days,4(6.2%) within 22-28 days and 6(9.2%) beyond 29 days  with P=15.91±9.30. The cause of secondary postpartum haemorrhage was retained bits of membrane 24(36.9%%), retained placental tissue 14(21.5%%), purpural sepsis 8(12.3%) and subinvolution of the uterus 19(29.2%).Out of 65 women with secondary PPH 32(49.2%) women received medical treatment in the form of uterotonic drugs and administration of antibiotic. Surgical treatment was given to 33(49.2%)women, check evacuation was done on 26(40%) women, Dilatation and evacuation(D&C) in 4 (6.2%), placental tissue were removed digitally in 2(3.1%) where the cervical os was open and haemostaic suture was taken in 1(1.5%) women with bleeding from the right cervical angle.

Conclusion: Secondary PPH is a rare complication but one that can result in severe maternal morbidity. We found that retained placental tissue and bits of membrane were the commonest cause of secondary PPH followed by subinvolution of the uterus and puerperal sepsis. Medical and surgical intervention were required in almost all the cases with equal frequency.

1. Dewhurst CJ. Secondary post-partum haemorrhage. J Obstet Gynecol Br Commonw 1966;73(1):53–8.
2. King PA, Duthie SJ, Ven D, Dong ZG, Ma HK. Secondary Postpartum Haemorrhage. Aust N Z J Obst Gynecol 1989;29(4):394-8.
3. Glazener CMA, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynecol 1995;102:282-7.
4. Rome RM. Secondary post partum Haemorrhage. Br J Obstet Gynecol 1975;82: 289-92.
5. Hoveyda F,Mac Kenzie IZ. Secondary postpartum haemorrhage: incidence, morbidity and current management. Br J Obstet Gyecol 2001;108:927-30.
6. Groom KM, Jacobson TZ. The management of secondary post partum haemorrhage. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A textbook of postpartum haemorrhage: a comprehensive guide to evaluation, management and surgical intervention. Duncow: Sapiens Publishing; 2006. p. 316–24.
7. Marchant S, Alexander J, Thomas P, Garcia J, Brocklehurst, Keene J. Risk factors for hospital admission related to excessive and/or prolonged postpartum vaginal blood loss after the first 24h following childbirth. Pediatr Perinat Epidemiol 2006;20(5):392 –402.
8. Mulic-Lutvica A, Axelsson O. Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue. Ultrasound Obstet  Gynecol 2006;28 (3):312–9.
9. Khong TY, Khong TK. Delayed postpartum haemorrhage: a morphologic study of causes and their relation to other pregnancy disorders. Obstet Gynecol 1993 ;82(1) :17–22.
10. Markos AR. Prostaglandin E2 suppositories in the treatment of secondary postpartum haemorrhage. J R Soc Med 1989;82:504–5.
11. Legrand AD, Rivière O, Dossou M, Vendittelli F. Risk Factors for Severe Secondary Postpartum Hemorrhages: A Historical Cohort Study. Birth 2015;42(3): 235-41.
12. Larsen JV, Janowski K, Krolilowski A. Secondary post partum haemorrhage due to uterine wound dehiscence. Cent Afr J Med 1995;41(9):294-6.
13. Neill AC, Nixon RM, Thornton S: A comparison of clinical assessment with ultrasound in the management of secondary postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2002;104:113–5.
14. Sengupta Dhar, Misra R. Postpartum Uterine Wound Dehiscence Leading to Secondary PPH: Unusual Sequelae. Case Rep in Obstet Gynecol 2012;2012:1-3.
15. Park HS, Shin JH, Yoon HK, Kim JH, Gwon DI, Ko GY et al Transcatheter Arterial Embolization for Secondary Postpartum Hemorrhage: Outcome in 52 Patients at a Single Tertiary Referral Center. J Vasc Interv Radiol 2014;25(11):1751-7.
16. Doumouchtsis SK, Papageorghiou, Arulkumaran S. Systematic Review of Conservative Management of Postpartum Hemorrhage: What to Do When Medical Treatment Fails. Obstet Gynecol Surv 2007;62(8):540-7.

17. Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009;9(55):1-10.
18. Fong A, Leake J, Pan D, Ogunyemi D. Demographic, institutional and obstetrical risk factors for postpartum haemorrhage mortality. J Obstet Gynaecol 2010;30:470-5.
19. Weydert JA, Benda JA. Subinvolution of the placental site as an anatomic cause of postpartum uterine bleeding:a review. Arch Pathol Lab Med 1994;130:1538–42.
20. Al-Mehaisen L, Al-Kuran O, Amarin ZO, Matalka I, Beitawi S, Muhtaseb A. Secondary postpartum hemorrhage following placental site vessel Subinvolution:a case report. Arch Gynecol Obstet 2008;278:585–7.
21. Tadesse W, Farah N, Hogan J, D’Arcy T, Kennelly M, Turner MJ. Peripartum Hysterectomy in the first decade of the 21st century. J Obstet Gynaecol 2011;31: 320-1.
22. Lédée N, Ville Y, Musset D, Mercier F, Frydman R, Fernandez H. Management in Intractable Obstetric Haemorrhage:An Audit Study on 61 Cases. Eur J Obstet Gynecol 2001;94:189-96.
23. Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract & Res Clin Obstet Gynecol 2008;22: 999-1012.

Dr Haelom Liegise

Former Junior Resident, Dept of Obstetrics and Gynaecology, R.I.M.S Imphal, Manipur