Management of Secondary Postpartum Hemorrhage

Understanding Secondary PPH vs. Infection

• Secondary postpartum hemorrhage (PPH) occurs between 24 hours and 6 weeks postpartum, with the most common causes being retained products of conception (RPOC), subinvolution of the placental bed, or infection, as stated by the American College of Radiology 1, 2
• The critical distinction is that antibiotics treat the infectious component, not the hemorrhage itself, according to the American College of Radiology 1

Diagnostic Workup

• Transvaginal ultrasound is the initial imaging modality to identify RPOC, infection, or vascular abnormalities, as recommended by the American College of Radiology 1, 2
• CT with IV contrast is reserved for hemodynamically stable patients when ultrasound is inconclusive or to identify active extravasation, hematomas, or complications like ovarian vein thromosis, as suggested by the American College of Radiology 1, 2

Cause-Specific Treatment

• RPOC: Surgical curettage is the definitive treatment, according to the American College of Radiology 1
• Vascular uterine anomalies/pseudoaneurysm: Arterial embolization is preferred, as stated by the American College of Radiology 1, 2

Critical Pitfalls

• Do not rely on antibiotics alone to stop bleeding—they only address the infectious component while the hemorrhage requires mechanical or surgical intervention, as warned by the American College of Radiology 1
• Antibiotic prophylaxis should be re-dosed if blood loss exceeds 1,500 mL, regardless of the initial cause, as recommended by the American Journal of Obstetrics and Gynecology 3